W. Va. BMS Provider Manual § 509.5.2

The Hospice must obtain a copy of this written certification no later than two calendar days after Hospice

care is initiated.

•

For the initial 90-day period, if the Hospice cannot obtain a written certification within two calendar

days, it must obtain oral certifications within two calendar days and written certification no later

than eight calendar days after the period begins (see West Virginia State Plan Appendix 3.1-A

and 3.1-B).

If these requirements are not met within the set timeline, the provider is not eligible for reimbursement of

Hospice services furnished before the date on which written certification is obtained.

Subsequent Recertification Periods:

A Hospice physician or Hospice advanced practice registered nurse (APRN) must conduct a face-to-face

recertification visit for each Hospice member whose total stay across all Hospices is anticipated to reach

180 days. The visit must occur no more than 30 calendar days prior to the 180-day recertification. The

physician and/or Hospice APRN must continue to visit that member no more than 30 calendar days prior

to every recertification thereafter, to gather clinical findings to determine continued eligibility for Hospice

care (in accordance with 42 CFR §418.22).

The written narrative associated with the 180-day recertification and every subsequent recertification

must include:

•

Date of the member’s face-to-face visit with the Hospice physician or Hospice APRN;

•

Clinical findings to determine whether the member continues to have a life expectancy of six

months or less;

•

The Hospice APRN must document all clinical findings and submit to the certifying Hospice

physician, signed and dated on a separate and distinct section of, or an addendum to, the

recertification form; and

•

Signature and date of signature by the Hospice physician(s) and the benefit period dates to which

the certification or recertification applies.

Authorization is required for all Hospice certifications and re-certifications. Appropriate documentation

must be submitted to the utilization management contractor (UMC) within eight calendar days of the

member’s election of Hospice. It is understood that due to the nature of Hospice services, services may

need to begin before the initial authorization is finalized and, in these instances, retrospective

authorization will be granted for members who meet the requirements of the program.

If the Hospice is not able to complete the face-to-face visit according to the above specifications, the

Hospice must discharge the member and Medicaid will no longer reimburse the Hospice for the member’s

Hospice services. Medicaid is not responsible for reimbursement of Hospice services during the period of

discharge.

When the face-to-face evaluation is completed by the Hospice physician or Hospice APRN, the Hospice

provider will be able to bill the Medicaid program for services.