N.J. Admin. Code § 10:53A-3.5

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:53A-3.5 - Services unrelated to the terminal illness

(a) The hospice beneficiary, by signing the Election of Hospice Benefits Statement, FD-378 (6/92) agrees to waive most regular Medicaid/NJ FamilyCare FFS services. However, Medicaid/NJ FamilyCare FFS covered services unrelated to the terminal illness, included in the plan of care, may be provided by approved Medicaid/NJ FamilyCare FFS providers upon approval of the interdisciplinary team of the hospice.

1. The reasons for providing unrelated services and the verification that the unrelated services are not, in any way, related to the terminal illness shall be documented in the plan of care by a member of the interdisciplinary team.

i. Documentation shall clearly specify those services that are related to and those services that are unrelated to the terminal illness.

ii. Services unrelated to the terminal illness are subject to the same coverage provisions, limitations, prior authorization requirements, and conditions applied to services available to other general non-hospice Medicaid/NJ FamilyCare FFS beneficiaries.

iii. All payments for services (except for physician's services) that are unrelated to the terminal illness may be denied if not approved by the interdisciplinary team, documented in the plan of care and on file in the patient's medical record.

(b) The unlimited number of subsequent 60-day periods beyond 180 days of hospice care must also be approved by the interdisciplinary team of the hospice as an integral part of the plan of care.

1. If an unlimited number of 60-day periods of hospice services is anticipated, the hospice shall document in the beneficiary's medical record, the approval of this period by the interdisciplinary team at the beginning of the first 60-day benefit period. Approval by the interdisciplinary team prior to the delivery of hospice services is required for payment for services.

2. A new Physician Certification/Recertification for Hospice Benefits Form, FD-385 (6/92) is required for the approval by the interdisciplinary team for each benefit period.

(c) The documentation of the approval of unrelated services and each subsequent 60-day period shall be filed in the beneficiary's medical record with the copy of the claim form and be made available upon request for post-payment review purposes.

N.J. Admin. Code § 10:53A-3.5

Amended by R.2003 d.320, effective 8/4/2003.
See: 34 New Jersey Register 2899(a), 35 New Jersey Register 3568(a).
Rewrote the section.