N.C. Medicaid Clinical Coverage Policy No. 3D § 5.2.2.2

The third (3rd) benefit period and each subsequent benefit period are 60

calendar days. The Hospice provider(s) shall create a prior approval

request and upload all the following documents listed below online

through the NCTracks Provider Portal for recertification:

a. NC Medicaid Hospice Prior Approval Authorization Form (DMA-

3212);

b. Hospice Recertification of Terminal Illness;

c. Physician Plan of Treatment - Order for care and services;

d. Face-To-Face Encounter

e. Supporting clinical documentation (i.e. medical history, nurses’ IDG

notes, etc.), and assessment tools used to measure beneficiary status or

decline. Hospice Assessment tool including, but not limited to,

Functional Assessment Scales (FAST); Palliative Performance Scales;

New York Heart Association Functional Classification Tool (NYHA),

Palmetto GBA Local Coverage Determinations.

Note: If above required documentation is not received, the recertification

prior approval request is denied.

Prior Approval (PA) requested for hospice services must be submitted on

behalf of the medical director or beneficiary’s attending physician via NC

Track at least ten calendar days before the end of the current benefit

period.

Note: The hospice physician, hospice nurse practitioner or physician

assistant may act as the beneficiary’s attending physician per beneficiary

choice according to 42 CFR 418.52(c)(4). Refer to Section 7.8.