MO HealthNet Hospice Provider Manual § 3.2

MHD does not provide standardized forms for the documents listed below, however any form used by providers must meet Medicare certification requirements and follow the policies in this manual.

Initial Plan of Care

All services provided by the hospice must be consistent with the initial plan of care. The initial plan of care provides a written plan stating the services, medical, and pharmaceutical care that the hospice makes a commitment to provide to the patient. The initial plan of care must contain the signatures of the members of the basic interdisciplinary group who are involved in the establishment of the plan of care. The plan of care should not be submitted to MHD but must be retained by the hospice and furnished to MHD or its representative upon request.

The following information is required to be included on the initial plan of care:

Participant’s name

Participant’s MO HealthNet ID number

Name of the hospice

Hospice NPI

Start of care date

All necessary information regarding the participant's condition and required treatments

Refer to Section 2.5 in this manual for more information on the plan of care.

Plan of Care Supplement

The plan of care supplement is used to update or amend the initial plan of care. This supplement is in effect at the time of and following the physician’s signature. The plan of care supplement should not be submitted to MHD but must be retained by the hospice and furnished to MHD or its representative upon request.

The following information is required to be included on the plan of care supplement:

Participant’s name

Participant’s MO HealthNet ID number

Name of the hospice

Hospice NPI

All necessary information regarding the participant's condition and required treatments.

Refer to Section 2.5 in this manual for more information on the plan of care.

Medication List

A medication list must be compiled per individual participant and be kept in the participant's file. It must include an explanation or interpretation of the coding used on the medication list to identify if the medication is needed for the palliation and management of the terminal illness or a related condition. MHD may provide reimbursement to the pharmacy when the medication is not related to the terminal illness or related conditions. The medication list must be updated each time there is a change in the participant’s pharmaceuticals.

Claims for medications that are not related to the terminal illness or related conditions are submitted by the Pharmacy through the Pharmacy Point of Sale system. A listing of therapeutic drug classes assumed to be related to the terminal illness can be found on the Hospice Fiscal Edit. Claims for medications in the Hospice Fiscal Edit are not reimbursed by MHD without prior authorization. MHD prior authorizes drugs on the Hospice Fiscal Edit only when it is determined the drugs are unrelated to the terminal diagnosis or a related condition.

The following information is required to be included on the medication list:

Participant’s name

Participant’s MO HealthNet ID number

Name of the hospice

Hospice NPI

List of participant’s medication

Code indicating responsible party