471 Neb. Admin. Code, ch. 36, § 007 - PRIOR AUTHORIZATION

All hospice services must be prior authorized. The hospice must submit prior authorization requests to the Department within 72 hours of the initial assessment. Prior authorization may be retroactive for up to seven days, based on the client's entry date into the hospice program. To request prior authorization, the hospice must submit:

1. Agency name and provider number;

2. Signed election statement;

3. Physician certification of terminal illness and 6 month or less life expectancy;

4. Hospice plan of care; and

5. List of all medications, biologicals, supplies, and equipment for which the hospice is responsible.

Claims may be denied when prior authorization is not completed.

Re-authorization must be requested for clients who surpass the six-month prognosis.

007.01 Clinical Criteria for Non-Cancer Diagnosis

Coverage of the Medicaid Hospice Benefit depends on a physician's certification that an individual's prognosis is a life expectancy of six months or less if the terminal illness runs its normal course. The client will be discharged from the Medicaid Hospice Benefit when the client improves or stabilizes enough that the six months or less prognosis is no longer accurate. The client may be re-enrolled for a new benefit period when a decline in the clinical status is such that the life expectancy is again six months or less.

36-007.01A Guidelines for Decline in Clinical Status: Clients will be considered to have a life expectancy of six months or less only when there is documented evidence of a decline in clinical status. Baseline data is established on admission to hospice through nursing assessment in addition to utilization of existing information from records. It is essential that baseline and follow-up determinations are documented thoroughly to establish a decline in clinical status.

Coverage of hospice care for clients not meeting the guidelines may be denied. Some clients may not meet the guidelines, yet still be appropriate for hospice care, because of co-morbidities or decline. Coverage for these clients may be approved through the prior authorization process.

Notes

471 Neb. Admin. Code, ch. 36, § 007