N.C. Medicaid Clinical Coverage Policy No. 3D, Attachment B(D)

The certifications or recertification must contain a brief narrative describing the clinical basis for

the beneficiary’s terminal prognosis. The hospice shall retain all certification statements and

attestations of face-to-face encounters. Note the following:

1.

The certification or recertification must contain the following:

a. Physician shall briefly synthesize the clinical information supporting the terminal diagnosis

and attest that he or she composed the narrative after reviewing the clinical information,

and where applicable, examining the beneficiary. The narrative must reflect the

beneficiary’s individual clinical circumstances.

b. The certification or recertification must include the election period dates to which it applies

and be signed and dated by the certifying or recertifying physician.

c. Initial certifications may be prepared no more than 15 calendar days prior to the effective

date of election.

d. Recertification may be prepared no more than 15 calendar days prior to the start of the

subsequent election period.

2.

Narratives associated with the third and later election period must also contain an explanation

of why the clinical findings of the face-to-face encounter support a life expectancy of six

months or less.