La. Medicaid Services Manual ch. 24 (Hospice), Appendix B

CERTIFICATION OF TERMINAL ILLNESS

Instructions for Completing the Bureau of Health Services Financing

Form Hospice - Certification of Terminal Illness

Purpose of the Bureau of Health Services Financing Form Hospice –

Certification of Terminal Illness

The purpose of the Bureau of Health Services Financing (BHSF) Form Hospice - Certification of

Terminal Illness (CTI) is to document written and verbal CTI for Medicaid beneficiaries.

Additionally, this form may be utilized for dual eligible (Medicare/Medicaid) beneficiaries.

NOTE: This form is not to be altered by the Hospice provider.

The CTI, BHSF Form Hospice - Notice of Election (NOE) and all related documents must be

electronically submitted via electronic prior authorization (e-PA) system. (See Appendix D for

contact information).

Completing the BHSF Form Hospice-CTI

For Medicaid-only beneficiaries, there must be two different signatures on the CTI. For dual

eligible (Medicare Part A) beneficiaries, only one physician’s signature is necessary.

Submission of the physician’s CTI is required all election periods. However, additional copies of

certification forms for all election periods must be made available to the Bureau upon request.

NOTE: A stamped physician’s signature is not acceptable on the certification. The physician must

date this form at time of his signature. No stamped dates are acceptable. Submitting forms

incorrectly may delay the hospice segment being added to the system. If the physician forgets to

date the certification; another signed and dated CTI can be obtained to verify when the certification

was obtained. The hospice approval date will be the date the signed and dated CTI is received in

the hospice program office if submitted beyond the 10-day time limit.

Patient Information

1. Patient Name - REQUIRED

Enter the beneficiary’s first name, middle initial and last name in this order.

2. Patient Medicaid Identification (ID) Number - REQUIRED

Enter the beneficiary’s 13-digit Medicaid ID number exactly as it appears in the

beneficiary’s current Medicaid information using the plastic Medicaid “swipe” card,

electronic Medicaid eligibility verification system (e-MEVS), or the recipient eligibility

verification system (REVS). Make certain that the last two digits are the correct individual

suffix for your beneficiary. The number must match the beneficiary’s name. If the patient

is not eligible for Medicaid, reimbursement is not made by Medicaid.

3. Patient’s Date of Birth (DOB) - REQUIRED

Enter the month, day and year of birth (MM-DD-YYYY) of patient.

Example: 06-12-1903.

Certification of Terminal Illness

For the first benefit period (90 days) both attending physician and the hospice medical director or

the physician member of the interdisciplinary team (IDT) must certify terminal illness.

Subsequent benefit periods (2 nd, 3rd, 4th, etc.) require only the signature of the hospice medical

director or the physician member of the IDT must certify terminal illness.

First Benefit Period (90 days)

4. Signature of Attending Physician - REQUIRED

This is the signature of the attending physician prior to electing hospice and currently

responsible for referring, certifying and signing the individual's plan of care (POC) for

medical care and treatment.

5. Date Signed (MM-DD-YYYY) - REQUIRED

The attending physician must enter the date at the time of signature.

6. Printed Name of Above Attending Physician - REQUIRED

Print the name of the attending physician currently responsible for certifying and signing

the individual's POC for medical care and treatment.

7. Signature of Hospice Medical Director or Physician Member of IDG - REQUIRED

This is the signature of the hospice medical director or physician member of IDT.

8. Date Signed (MM-DD-YYYY) - REQUIRED

The hospice medical directo r or physician member of the IDT must enter date at time of

signature.

9. Printed Name of Hospice Medical Director or Physician Member of IDT Signee -

REQUIRED

Print the name of the hospice medical director or physician member of the IDT who signed

in as per number seven.

Second Benefit Period (90 Days)

10. Signature of Hospice Medical Director or Physician Member of IDG - REQUIRED

This is the signature of the hospice medical director or physician member of the IDT.

11. Date Signed (MM-DD-YYYY) - REQUIRED

The hospice medical directo r or physician member of the IDT must enter the date at the

time of signature.

12. Printed Name of Hospice Medical Director or Physician Member of IDT Signee -

REQUIRED

Print the name of the hospice medical director or physician member of the IDT who signed

in as per number 10.

Third Benefit Period (60 Days)

13. Signature of Hospice Medical Director or Physician Member of IDT - REQUIRED

This is the signature of the hospice medical director or physician member of the IDT.

14. Date Signed (MM-DD-YYYY) - REQUIRED

The hospice medical directo r or physician member of the IDT must enter the date at the

time of signature.

15. Printed Name of Hospice Medical Director or Physician Member of IDT Signee -

REQUIRED

Print the name of the hospice medical director or physician member of the IDT who signed

in as per number 13.

Referring Physician Narrative Statement

16. Narrative Statement - REQUIRED

The attending/referring physician must complete a narrative providing the diagnosis,

prognosis and the justification for hospice care. The narrative must be completed prior to

the election of hospice care. The physician’s signature is required.

The narrative must include a statement under the physician signature attesting that by

signing, the physician confirms that they composed the narrative based on their review of

the beneficiary’s medical record or, if applicable, their examination of the patient.

17. Signature of the Referring Physician - REQUIRED

This is the signature of the referring physician.

18. Date Signed (MM-DD-YYYY) - REQUIRED

The referring physician must enter the date at the time of signature.

19. Printed Name of the Referring Physician - REQUIRED

Print the name of the referring physician who signed in as per number 17.

NOTE: If additional periods are to be certified, use an additional form.

Verbal Verification (within two days of election date)

This section must be used to document that verbal verification was obtained from the physician as

named in this section confirming the beneficiary’s prognosis of life expectancy of six months or

less if the terminal illness runs its course. Either the verbal or written certification must be obtained

within two days of the election date so hospice care can begin.

20. Printed Name of Physician Who Gave Verbal Verification - REQUIRED

Print the name of the physician who gave verbal verification of the beneficiary’s terminal

illness.

21. Signature of the IDT Member Taking Referral - REQUIRED

This is the signature of the member of the IDT who obtained the physician’s verbal CTI.

22. Printed Name of IDT Member Signee Taking Referral - REQUIRED

Print the name of the IDT who signed in as per number 21.

23. Date Signed (MM-DD-YYYY) - REQUIRED

The IDT member must enter date at time of signature.