Del. Medical Assistance Program Hospice Provider Specific Policy Manual § 1.2

1.2.1 Coordination of physician certification for terminal illness for Medicare dual

eligible.

1.2.1.1 DMAP will accept the Medicare Physician Certification of terminal illness to fulfill

the Medicaid requirement.

1.2.2 Timing of the certification:

• The hospice must obtain written certification of terminal illness for each of the

periods listed, even if a single election continues in effect for an unlimited

number of periods

• The hospice must obtain the written certification before it submits a claim for

payment. If the hospice cannot obtain the written certification within 2

calendar days, after a period begins, it must obtain an oral certification within

2 calendar days and the written certification before it submits a claim for

payment.

• Certifications may be completed no more than 15 calendar days prior to the

effective date of election. Recertifications may be completed no more than 15

calendar days prior to the start of the subsequent benefit period.

1.2.3 Content of the Certification

1.2.3.1 Certification will be based on the physician's or medical director's clinical

judgment regarding the normal course of the individual's illness. The certification

must conform to the following requirements:

1.2.3.2 The certification must specify that the individual's prognosis is for a life

expectancy of 6 months or less if the terminal illness runs its normal course.

1.2.3.3 Clinical information and other documentation that support the medical prognosis

must accompany the certification and must be filed in the medical record with the

written certification. Initially, the clinical information may be provided verbally, and

must be documented in the medical record and included as part of the hospice's

eligibility assessment.

1.2.3.4 The physician must include a brief narrative explanation of the clinical findings

that supports a life expectancy of 6 months or less as part of the certification and

recertification forms, or as an addendum to the certification and recertification

forms.

• If the narrative is part of the certification or recertification form, then the

narrative must be located immediately prior to the physician's signature.

• If the narrative exists as an addendum to the certification or recertification

form, in addition to the physician's signature on the certification or

recertification form, the physician must also sign immediately following the

narrative in the addendum.

• The narrative shall include a statement directly above the physician signature

attesting that by signing, the physician confirms that he/she composed the

narrative based on his/her review of the patient's medical record or, if

applicable, his/her examination of the patient.

• The narrative must reflect the patient's individual clinical circumstances and

cannot contain check boxes or standard language used for all patients.

1.2.3.5 All certifications and recertification’s must be signed and dated by the

physician(s), and must include the benefit period number and dates to which the

certification or recertification applies.

1.2.4 Sources of Certification

• For the initial 90-day period, the hospice must obtain written certification

statements (and oral certification statements if required) from: The medical

director of the hospice or the physician member of the hospice

interdisciplinary group; and the individual's attending physician, if the

individual has an attending physician. An attending physician is a physician

who is a doctor of medicine or osteopathy and is identified by the individual at

the time he or she elects to receive hospice care as having the most

significant role in the determination and delivery of the individual’s medical

care.

• For subsequent periods, the only requirement is certification by the medical

director of the hospice or the physician member of the hospice

interdisciplinary group.

1.2.5 Maintenance of certification records. Hospice staff must:

• Make an appropriate entry in the patient's medical record as soon as

they receive an oral certification; and

• File written certifications in the medical record.