130 CMR 437.411 - Certification of Terminal Illness

(A) Timing of Certification. The hospice provider must obtain written certification of terminal illness for each of the periods listed in 130 CMR 437.407, even if a single election continues in effect for an unlimited number of periods, as provided in 130 CMR 437.412.

(1) If the hospice provider cannot obtain the written certification within two calendar days after a period begins, it must obtain an oral certification within two calendar days after a period begins and the written certification before the hospice provider submits a claim for payment to the MassHealth agency.

(2) Certifications may be completed no more than 15 calendar days prior to the effective date of election.

(3) Recertifications may be completed no more than 15 calendar days prior to the start of the subsequent election period.

(B) Face-to face Encounter. When the hospice provider anticipates the member will reach their third benefit period, the hospice physician or hospice nurse practitioner must have a face-to-face encounter with the member. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to the third benefit period recertification, and every benefit period recertification thereafter to gather clinical findings to determine the member's continued eligibility for hospice care. This requirement applies to members receiving hospice services within the same hospice organization. The hospice physician or hospice nurse practitioner must attest in writing that he or she had a face-to-face encounter with the member.

(1) The attestation documenting the face-to-face encounter, which must be a separate and distinct part of the member's recertification for hospice services, or an addendum to the recertification associated with the third election period, must be clearly titled as the "Face-to-Face Encounter", and include the following information:

(a) accompanying signature, and date signed by the authorized individual who performed the visit;

(b) date of the visit;

(c) clinical findings to determine continued hospice eligibility; and

(d) when the hospice NP performs the face-to-face encounter, the attestation must also state that the clinical findings were provided to the certifying physician for use in determining continued eligibility for hospice care.

(2) Dual-eligible Members. For dual-eligible members, MassHealth will consider a face-to-face encounter conducted in accordance with all requirements of 42 CFR 418.22 to meet the face-to-face encounter requirements described in 130 CMR 437.411(C).

(C) Contents of the Certification Statement. The certification of the member's terminal illness must be in writing and completed by either the medical director of the hospice or the physician member of the hospice interdisciplinary team, in collaboration with the member's attending physician, if the member has an attending physician. The certification must also meet the following requirements.

(1) The certification must specify that the member's life expectancy is six months or less, if the terminal illness runs its normal course;

(2) The certification must include clinical information and other documentation that supports the medical prognosis of six months or less, and this documentation must be filed in the member's medical; record;

(3) The certification must include a brief narrative written by the physician completing the certification or recertification. The narrative must explain the clinical findings that support a life expectancy of six months or less and must include a statement attesting that by signing, the physician confirms that the narrative was composed personally by the physician based on his or her review of the member's medical record or, if applicable, his or her examination of the member. The narrative associated with the member's third benefit period with the same hospice provider must also include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of six months or less. The narrative must reflect the member's individual clinical circumstances and may not contain checkboxes or standard language used for all members. The narrative must also be a part of the certification or recertification forms, or as an addendum to the certification and recertification forms;

(a) If the narrative is part of the certification or recertification form, the narrative must be located immediately before the physician's signature; or

(b) If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.

(4) For recertifications associated with the member's third benefit period and any subsequent election period, the recertification must also include documentation of the face-to-face encounter as described in 130 CMR 437.411(B)

(5) The certification must be signed and dated by the physician completing the cerification (6) The certification must include the benefit period dates to which the certification or recertification applies.

(D) Obtaining Certification. For the first 90-day election period of hospice services to be covered by MassHealth, the hospice provider must obtain written certification statements of the member's terminal illness from either the medical director of the hospice or the physician member of the hospice interdisciplinary team, and from the member's attending physician, if the member has an attending physician.

(E) Recertification for Subsequent Periods. For the subsequent 90-day and 60-day extension periods, the hospice must obtain, at the beginning of the period, a written certification statement from either the medical director of the hospice or the physician member of the hospice interdisciplinary team. The new certification must be on file in the member's clinical record before the submission of a claim.

Notes

130 CMR 437.411

Amended by Mass Register Issue 1353, eff. 12/1/2017. Amended by Mass Register Issue 1485, eff. 1/1/2023.