MO HealthNet Hospice Provider Manual § 3.1

The forms listed in this section are the MO HealthNet Hospice standardized forms.

Hospice Election Statement

The Hospice Election Statement is required to enroll a MO HealthNet participant in a hospice. This form should be submitted within five (5) days of execution. The Hospice Election Statement may be faxed to MO HealthNet Division (MHD) at (573) 526-2041. Do not routinely follow the faxed form with a copy in the mail. Below are the instructions to complete this form.

Field Number | Field Name | Instructions for Completion

1 | Participant Name | Enter last name, first name, and middle initial as shown on the MO HealthNet ID card

2 | Date of Birth | Enter date of participant's birth in MMDDYY format

3 | MO HealthNet ID Number | Enter the eight (8) digit MO HealthNet ID number exactly as it appears on the participant's ID card or letter

4 | Name of Hospice | Enter hospice name.

5a | NPI | Enter the 10-digit hospice National Provider Identifier (NPI).

5b | Taxonomy Code | Enter Hospice Taxonomy Code for NPI reported in 5a

6 | Hospice Telephone Number | Enter telephone number of hospice

7 | Attending Physician Name | Enter name of attending physician

8 | Employed by Hospice | Choose ‘Yes’ if the attending physician is employed by the hospice and ‘No’ if the attending physician is not employed by the hospice

9 | NPI | Enter the 10-digit NPI of the attending physician. If attending physician is not a MO HealthNet provider enter letters “NA”.

10 | Telephone Number | Enter telephone number of the attending physician

11 | Nursing Home Name | Enter nursing facility (NF) name as it appears in the hospice’s NF or intermediate care home agreements and on the Hospice-NF Contract Update form

12 | NPI | Enter the 10-digit NPI of the NF or intermediate care home as indicated on the Hospice-NF Contract Update form

13 | Telephone Number | Enter the telephone number of the NF or intermediate care home

14 | Primary Diagnosis (ICD Code) | Enter the participant's primary terminal diagnosis code as found in the International Classification of Diseases (ICD) diagnosis listing

15 | Secondary Diagnosis | Enter the secondary terminal diagnosis code as found in the ICD diagnosis listing

Date Hospice Election to Begin | Enter the date that the participant’s hospice election will begin

Signature of Participant/Participant Representative | The signature of the participant should be obtained whenever possible. If the participant is not available or is unable to sign their name, the participant representative is required to sign.

Signature of Witness | A witness signature is required when the participant representative signs.

If MHD returns a Hospice Election Statement to the hospice provider due to missing documentation or signatures, the hospice provider must return the Hospice Election Statement to MHD with the requested updates in order for the election to be recorded on the patient’s medical file.

The hospice must retain the Hospice Election Statement and furnish it to MHD or its representative upon request.

Facility Update Form

The Hospice-NF Contract Update form is utilized by the hospice to notify MHD of each NF or intermediate care home with whom the hospice has a contract/agreement to provide hospice care to the NF or intermediate care home resident(s). A comprehensive list of contracted NFs must be submitted as a requirement of provider participation. The hospice must submit this form as notification to MHD when a new contract/agreement is signed or when a contract is canceled.

The Hospice-NF Contract Update form must be completed by the hospice and submitted to MHD before NF room and board (revenue code: 0658) payments can be made to the hospice. Failure to submit this form results in denial of all hospice claims for NF room and board charges. The form is due 15 days prior to billing for NF or intermediate care home room and board.

Information required on the form:

Hospice name

Hospice MO HealthNet Provider ID

NF or intermediate care home MO HealthNet Provider ID

NF or intermediate care home name

Contract begin date MMDDYY

Contract end date MMDDYY (when applicable)

Providers should not complete the ‘End Date’ column with dates in the future, this column is used only to notify MHD of an actual contract cancellation. The hospice must notify MHD when a new contract/agreement is signed, or if a contract is canceled. This notification must also be submitted on a Hospice-NF Contract Update form. The information from the form is entered on the MHD hospice provider file and is accessed for claims processing. Hospice claims for nursing home room and board charges may be denied if this form is not submitted and updated when necessary.

The hospice and the NF or intermediate care home must retain a copy of the agreement and a Hospice-NF Contract Update form advising of this agreement must be on file prior to submitting claims for NF or intermediate care home room and board services. Providers may submit this information to MMAC.ProviderEnrollment@dss.mo.gov, fax to (573) 634-3105, or to the following address:

Missouri Medicaid Audit and Compliance Unit

Provider Enrollment Unit

P.O. Box 6500

Jefferson City, Missouri 65102-6500

Certificate of Medical Necessity

A completed Certificate of Medical Necessity is required to request coverage for the following physician services:

Additional medically necessary office visits

Concurrent care provided by second physician for the same diagnosis

The form must be attached to the claim on which the service is billed. For more information on the Certificate of Medical Necessity refer to the General Sections Manual.

Physician Certification of Terminal Illness

The Physician Certification of Terminal Illness is required as part of the election process to certify that the participant is terminally ill. Refer to Section 2.5 in this manual for more information on this form.

MHD provides a standardized form that meets Medicare Certification requirements. Participants who qualify may receive hospice care for two (2) 90-day benefit periods, followed by an unlimited number of 60-day periods while the individual remains in hospice care. This form must be used for the initial certification of terminal illness and the recertification for all subsequent benefit periods. Space for certifications for 13 benefit periods is provided on this form. Should the participant enter the fourteenth benefit period, providers should start a new Physician Certification of Terminal Illness and renumber those re-certifications which exceed the thirteenth period. The hospice provider must submit certification and/or recertification for specific benefit periods before billing for that time frame. If the certification date(s) for the specific benefit period is not provided, the hospice claims will deny.

According to the Department of Health and Senior Services (DHSS), Bureau of Home Care and Rehabilitative Standards, the hospice may not date the signature(s) of the attending physician or the hospice medical director. The dates must be entered on the form by the respective physicians. Failure to comply with this rule may result in denial or recoupment of hospice payments.

The attending physician must sign the Physician Certification of Terminal Illness within eight (8) days of the date of the hospice election. For the initial election period, the form is due to MHD within 10 days of the submission of the Hospice Election Statement. For recertifications, the form is due to MHD within five (5) days of the recertification due date.

Providers should allow 10 days after submitting the Physician Certification of Terminal Illness to MHD for the information to be processed. Providers should not submit claims before 10 days have elapsed. The hospice is required to retain one (1) copy of the completed form for their records and furnish it to MHD or its representative upon request.

The Physician Certification of Terminal Illness may be faxed to MHD at (573) 526-2041. Do not routinely follow the faxed form with a copy in the mail. Below are the instructions to complete the Physician Certification of Terminal Illness.

Field Name | Instructions for Completion

Participant Name | Enter last name, first name, and middle initial

MO HealthNet Identification Number | Enter the eight (8) digit MO HealthNet ID number exactly as it appears on the participant's ID card or letter

Participant Health Insurance Claim (HIC) Number | Enter the participant’s HIC number if the participant has Medicare

Social Security Number | Enter the participant’s Social Security Number

Hospice Information

Field Name | Instructions for Completion

Name of Hospice | Enter the name of the hospice

Hospice NPI | Enter the 10-digit hospice NPI

Hospice Medicare Provider Identifier | Enter the hospice MO HealthNet ID number

Provider Taxonomy Code | Enter Hospice Taxonomy Code

Initial Certification 90 Days

Field Name | Instructions for Completion

Initial Certification From Date | From date of benefit period

Thru Date | Thru date of benefit period

Verbal Order – Attending Physician | Name of attending physician who gave verbal order

Date of Verbal | Date of verbal order

Attending Physician Signature | Signature of Attending Physician

Date of Signature | Date of signature by the Attending Physician which must be entered by the physician

Verbal Order – Medical Director | Name of medical director who gave verbal order

Date of Verbal | Date of verbal order

Medical Director Signature | Signature of hospice Medical Director

Date of Signature | Date of signature by the Medical Director which must be entered by the Director

Recertification – For each selection period

Field Name | Instructions for Completion

Recertification From Date | From date of recertification period

Thru Date | Thru date of recertification period

Physician Signature | Signature of recertifying Physician

Date of Signature | Date of signature by the recertifying physician which must be entered by the physician

Notification of Termination of Hospice Benefits

The Notification of Termination of Hospice Benefits is a standardized form that must be used to notify MHD when a participant’s hospice benefit is terminated. This form is used if the participant chooses to revoke hospice benefits, changes designated hospices, is decertified due to a change in the terminal prognosis, moves from the hospice service area, or dies while on hospice.

Revocation of MO HealthNet Hospice Benefits by Participant Choice

When a participant chooses to discontinue hospice benefits to seek active treatment of the disease, or decides against using hospice benefits for some other reason, the Notification of Termination of Hospice Benefits is required. The participant’s benefits will revert to regular MO HealthNet coverage. The hospice provider is reimbursed for the date of revocation. The participant resumes MO HealthNet coverage for services related to the terminal illness the day following the day of revocation.

Section I of the Notification of Termination of Hospice Benefits should be completed. Refer to the instructions to complete this form below.

Change of Designated Hospice

When a participant transfers from one hospice provider to another hospice provider in the same or different area the newly designated hospice must verify that a Notification of Termination of Hospice Benefits indicating a change of designated hospice, was completed by the original hospice by viewing the participant’s copy of the form. If the form was not completed, the new hospice must complete the form and submit a copy to the original hospice and to MHD. Refer to Section 2.5 in this manual for more information on a new election.

Section II of the Notification of Termination of Hospice Benefits should be completed. Refer to the instructions to complete this form below.

Decertification of Terminal Illness

When the attending physician or the hospice’s medical director has determined that the participant’s condition has improved, or the prognosis has otherwise changed such that the physician does not expect the participant to expire within six (6) months, the Notification of Termination of Hospice Benefits is required.

Section IIII of the Notification of Termination of Hospice Benefits should be completed. Refer to the instructions to complete this form below.

Discharge Due to Patient Relocation

The Notification of Termination of Hospice Benefits is required when a hospice patient leaves the hospice provider’s service area. MHD provides a standardized form, Notification of Termination of Hospice Benefits that must be used when the patient relocates from the hospice service area. The date designated on the form is the effective date of the termination of hospice benefits.

Section IV of the Notification of Termination of Hospice Benefits should be completed. Refer to the instructions to complete this form below.

Notification of Death of Patient

The hospice is required to notify MHD within five (5) days following a MO HealthNet participant’s death by submitting a Notification of Termination of Hospice Benefits. Although the hospice may continue spiritual counseling and bereavement services for the family after the participant’s death, MO HealthNet hospice benefits are terminated effective on the date of death.

Section V of the Notification of Termination of Hospice Benefits should be completed. Refer to the instructions to complete this form below.

Notification of Termination of Hospice Benefits Instructions

The Notification of Termination of Hospice Benefits must be received within five (5) days of the change or termination of benefits. The completed form may be faxed to MHD at (573) 526-2041. The hospice must retain the form and furnish it to MHD or its representative upon request. Below are the instructions to complete this form.

Field Name | Instructions for Completion

Participant Name | Enter last name, first name, and middle initial

MO HealthNet Identification Number | Enter the eight (8) digit MO HealthNet ID number exactly as it appears on the participant's ID card or letter

Name of Hospice | Enter the name of the hospice

Provider Information

Field Name | Instructions for Completion

Provider Name | Enter the name of the provider

National Provider Identifier (NPI) | Enter the 10-digit NPI

Taxonomy Code | Enter Taxonomy Code

Medicare ID Number | Enter the Medicare ID number certified by Medicare

Medicare Provider Identifier | Enter the Medicare Provider Identifier assigned through the National Plan and Provider Enumeration System (NPPES) necessary for anyone who wants to bill Medicare for services rendered

Discharge Information

Field Name | Instructions for Completion

Reason for Discharge | Choose the reason for discharge and complete the corresponding section on the form

Section I – Revocation of Hospice Benefits by Patient Choice

Field Name | Instructions for Completion

Designated Date | Effective date of revocation; a participant may not designate an effective date earlier than the date of signature

Patient or Patient Representative Signature | Signature of the patient or the patient’s representative

Date | Date the signature is obtained

Witness Signature | A witness signature is required when the patient representative signs

Date | Date the witness signature is obtained (if applicable)

Section III – Decertification of Designated Hospice Provider

Field Name | Instructions for Completion

Effective Date | Enter the effective date of the termination of hospice benefits

Hospice Representative Signature | Signature of the Medical Director or attending physician who is providing the new prognosis decertifying the patient

Date | Date the signature is obtained

Section IV – Discharge Due to Patient Relocation

Field Name | Instructions for Completion

Effective Date | Enter the effective date of the termination of hospice benefits

Hospice Representative Signature | Signature of the hospice representative

Date | Date the signature is obtained

Section V – Death of Patient While on Hospice Service

Field Name | Instructions for Completion

Date Patient Expired | Enter the participant’s date of death

Hospice Representative Signature | Signature of the hospice representative

Date | Date the signature is obtained

Time Frames for Submission of Forms

Effective management of the Hospice Program requires the timely submission of forms by the hospice provider. It is the hospice provider’s responsibility to timely submit all documentation substantiating required signatures and dates to MHD. MHD verifies receipt of the required documentation and the accuracy of signatures and dates. Payment of hospice claims is dependent upon receipt of correctly completed documentation. If accurate documentation is not submitted to MHD timely, hospice claims will deny. Late submissions can cause denial of services to participants, denial of payments to providers, and incorrect payments. Each piece of documentation must contain the participant's MO HealthNet ID number for identification purposes.

The list below is to serve as a guide to aid the provider in effective management of hospice form submissions. The information listed below must be received by MHD within the number of days shown. The days shown in the ‘Due’ column are counted from the date the form is executed. Failure to submit required documentation within these guidelines may result in denial of hospice claims or recoupment of MO MHD payments.

Hospice Election Statement

Signature Requirements | Due | Submit

The signature of the patient should be obtained whenever possible. If the patient is not available or is unable to sign their name, the patient representative is required to sign. A witness signature is required when the patient representative signs. | As soon as possible | Fax: (573) 526-2041

Hospice-Nursing Facility (NF) Contract Update

Due | Submit

Due 15 days prior to billing for nursing facility or intermediate care home Room & Board | MMAC.ProviderEnrollment@dss.mo.gov; Fax: (573) 634-3105; Address listed in Section 2.12 of this manual

Physician Certification of Terminal Illness

Signature Requirements | Due | Submit

Initial Certification - The attending physician and hospice Medical Director must date and sign for the initial certification. | Due within eight (8) days of Hospice Election Statement | Fax: (573) 526-2041

Recertification - The recertifying physician must sign and date for each recertification | Due within five (5) days of recertification due date | Fax: (573) 526-2041

Notification of Termination of Hospice Benefits

Section | Signature Requirements | Due | Submit

Section I – Revocation of Hospice Benefits by Patient Choice | Signature of the patient or the patient’s representative. A witness signature is required when the patient representative signs. | Due within five (5) days of the Revocation | Fax: (573) 526-2041

Section II – Change of Designated Hospice Provider | Signature of the participant, participant’s representative, or hospice representative | Due within five (5) days of the Change in Designated Hospice Provider | Fax: (573) 526-2041

Section III – Decertification of Terminal Illness by Physician | Signature of the Medical Director or attending physician who is providing the new prognosis decertifying the patient | Due within five (5) days of the Decertification | Fax: (573) 526-2041

Section IV – Discharge Due to Patient Relocation | Signature of the hospice representative | Due within five (5) days of the Relocation | Fax: (573) 526-2041

Section V – Death of Patient While on Hospice Services | Signature of the hospice representative | Due within five (5) days of the Death of Patient | Fax: (573) 526-2041