Reminders on Hospice Policy

Clinical review is not required for North Carolina Medicaid and NC Health Choice hospice services until after the completion of the first and second 90-day benefit period.   

• First Benefit Period - The Hospice provider must upload into the NCTracks Provider Portal the prior approval (PA) request and the election statement within six calendar days of the effective date for hospice election. This notifies NC Medicaid of the beneficiary’s election of hospice services.  
• Second Benefit Period - Only the PA request is entered in NCTracks.
• Third and Subsequent Benefit Periods and Certification PA Requirements - The Hospice provider shall upload the required documents into the NCTracks provider portal every 60-day benefit period. The third benefit period requires submission of a hospice face-to-face encounter which must occur no more than 30 calendar days prior to the third benefit period and each subsequent benefit period thereafter.
   

Hospice providers shall upload all required documents via the NCTracks provider portal for the third and subsequent benefit periods. 

• NC Medicaid Hospice Prior Approval Authorization Form (NC DHB-3212);
• Hospice Recertification of Terminal Illness;
• Physician Plan of Treatment - Order for care and services;
• Face-To-Face Encounter; and,
• Supporting clinical documentation (e.g., medical history, nurses’ notes, interdisciplinary group meeting notes [IDG notes], etc.)

The Hospice provider shall submit a PA request within:

• Six calendar days of the election of the Medicaid, Medicaid-pending or NC Health Choice Hospice benefit;
• Ten calendar days of the start of the second and each subsequent benefit period; and
• Six calendar days of the start of care, if Medicare is the primary payer and Medicaid is providing coverage for nursing home room and board.

Note: Effective Nov. 1, 2017, all prior approval (PA) requests, regardless of benefit period, require a one-time upload of the hospice service election statement. In addition, documents related to the current benefit period, per policy, will also be uploaded into the NCTracks provider portal at that time.