New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 53A - HOSPICE SERVICES MANUAL
Subchapter 2 - PROVIDER REQUIREMENTS
Section 10:53A-2.3 - Physician certification and recertification
Universal Citation: NJ Admin Code 10:53A-2.3
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The hospice shall follow these policies and procedures to obtain physician certification of the applicant's terminal illness and to certify that hospice services are reasonable and necessary for the palliation and management of the terminal illness or related conditions.
1. The attending physician, who must be a doctor of medicine (M.D.) or osteopathy (D.O.), is the one identified by the Medicaid/NJ FamilyCare FFS beneficiary at the time the beneficiary elects to receive hospice services as the primary physician in the determination and the delivery of the beneficiary's medical care.
2. The written Physician Certification/Recertification for Hospice Benefits Form, FD-385 (Form #8 in the Appendix incorporated herein by reference) shall be obtained within two calendar days after hospice care is initiated for the first period of hospice coverage.
i. If the hospice does not obtain written certification within two days after the initiation of hospice care, a verbal certification may be obtained within these two days and a written certification no later than eight calendar days after care is initiated. If these requirements are not met, no payment can be made for any days prior to the certification.
ii. The signing of the written form shall be done by the hospice Medical Director, or physician of the interdisciplinary team and the attending physician (if the applicant has an attending physician), and shall include the statement that the applicant's medical prognosis is such that the life expectancy is six months or less.
3. If the hospice beneficiary revokes the hospice benefit package and then reenters the hospice in any subsequent period, the hospice shall obtain, no later than seven calendar days after the beginning of that period, a written Physician Certification/Recertification for Hospice Benefits Form, FD-385 prepared by the Medical Director of the hospice or the physician member of the hospice's interdisciplinary group.
4. For subsequent recertifications, a written recertification must be obtained no later than two business days after the period begins (after the first 90-day benefit period, after the next 90-day benefit period, and after each subsequent 60-day period). The Medical Director of the hospice or physician member of the interdisciplinary team shall recertify that the individual is terminally ill and that hospice services are reasonable and necessary for the palliation and management of the terminal illness or related condition, and, in addition, recertify the necessity of the continuing need for hospice services.
5. In addition, the individual's attending physician is required to recertify the terminal illness for each subsequent 60-day benefit period, as described below:
i. An additional Physician Certification/Recertification for Hospice Benefits Form, FD-385 must be obtained prior to each subsequent 60-day period but no later than two days after the period begins.
6. The hospice must retain the Physician Certification/Recertification for Hospice Benefits Form(s), FD-385 on file for review by the Division in the beneficiary's medical record.
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