N.D. Medicaid Billing and Policy Manual, Hospice Services, Covered Services and Limits

General Provider Policies

The General Provider Policies details basic coverage requirements for all services.

Basic coverage requirements include:

• The provider must be enrolled in ND Medicaid;

• Services must be medically necessary;

• The member must be eligible on the date of service; and

• If appliable, the service has an approved service authorization.

The hospice must provide the below services on a 24-hour basis. Core services must

routinely be provided directly by hospice employees. The hospice may contract for

supplemental services during periods of peak patient load or for extraordinary

circumstances. A written plan of care must be prepared for each patient, and services

must be provided by appropriately qualified personnel.

Core Services include:

• Nursing services provided by or under the supervision of a registered nurse;

• Social services provided by a social worker under the direction of a physician;

• Services performed by a physician, dentist, optometrist, or chiropractor; and

• Counseling services provided to the member and family members or other

persons caring for the member at the member’s home to assist in minimizing the

stress and problems that arise from the terminal illness, related conditions, and

the dying process.

Supplemental Services include:

• Inpatient hospice care, including procedures necessary for pain control and acute

or chronic symptom management;

• Inpatient respite care;

• Medical equipment supplies and drugs. Medical equipment including self-help

and personal comfort items related to the palliation or management of the

member’s terminal illness must be provided by the hospice for use in the

member’s home. Medical supplies include supplies specified in the written plan of

care. Drugs include those used to relieve pain and control symptoms for the

member’s terminal illness;

• Home health aide services and homemaker services which include personal care

services and household services, such as changing a bed, light cleaning and

laundering, necessary to maintain a safe and sanitary environment in areas of

the home used by the member. Aide services must be provided under the

supervision of a register nurse; and

• Physical therapy, occupational therapy, and speech and language pathology

services provided for symptom control or to maintain activities of daily living and

basic functional skills.

Plan of Care

All hospice care and services furnished to patients and their families must follow an

individualized written plan of care established by the hospice interdisciplinary group in

collaboration with the attending physician (if any), the patient or representative, and the

primary caregiver in accordance with the patient's needs, if any of them so desire. The

hospice must ensure that each patient and the primary care giver(s) receive education

and training provided by the hospice as appropriate to their responsibilities for the care

and services identified in the plan of care.

The hospice interdisciplinary group, in collaboration with the individual's attending

physician, (if any) must review, revise and document the individualized plan as

frequently as the patient's condition requires.

Physician Certification

For the first 90-day period of hospice coverage, the hospice provider must obtain, no

later than 2 calendar days after hospice care is initiated, (that is, by the end of the third

day), oral or written certification of the terminal illness by the medical director or the

hospice or physician member of the hospice interdisciplinary group (IDG), and the

individual’s attending physician if the individual has an attending physician. The hospice

must obtain certification before it submits a claim for payment. Certifications may be

completed no more than 15 calendar days prior to the effective date of election and

recertifications may be completed no more than 15 calendar days prior to the start of

the subsequent benefit period.

Content of the Certification

The certification statement must include:

• A statement indicating the member’s medical prognosis is a life expectancy of six

months or less;

• Clinical information and documentation that supports the medical diagnosis;

• A brief narrative explanation of the clinical findings that supports the life

expectancy of 6 months or less; and

• Physician(s) signature and the benefit period dates to which the certification or

recertification applies.

The Procedure Code Look-up Tool can be used to identify if a procedure code is

covered by ND Medicaid along with code specific details such as ORP requirements,

Service Authorization requirements, and current rates.