Thank you for being a Jefferson Health Plans’ participating provider. In preparation for upcoming provider monitoring that Jefferson Health Plans’ Special Investigation Unit will performing, we would like to make you aware of some recent findings of Pennsylvania Department of Human Services (DHS) medical records reviews for Hospice providers.

Below is a summary of those findings and applicable regulatory guidance to assist in ensuring the highest level of accuracy in the documentation of Hospice services.

• The patient’s medical record should include sufficient documentation related to the patient's terminal illness, including an applicable terminal illness form.  Please refer to[55 Pa. Code§ 1101.51 (e)(1 )(x); and § 1130.22(1 )(ii)(2)(i)(ii)(B). See also 55 Pa. Code§§ 1130.21 (3), and 1130.91.] for more information.
  • Medical records should always include notice of rights and responsibilities. [55 Pa. Code §§ 1130.52(a)(1)(3)(4)(5)(b) and 1130.61 (3).]
  • Medical record must be legible, accurate, complete and chronologically reflect the evaluation and treatment of the recipient. [55 Pa. Code Chapters 1101, 1130, and all applicable MA Bulletins.]
  • Medical record should include sufficient documentation of social worker visits and bereavement counseling notes, as specified in the plan of care. [55 Pa. Code§§ 1130.52(a)(1)(b), 1130.61(4) and 1130.62(2) and (4).
  • Oral certification of terminal illness was not followed up with a written certification in a timely manner.[55 Pa. Code § 1101.51(e)(1)(x); and 55 Pa. Code § 1130.22(1)(2). See also 55 Pa. Code § § 1130.21(3) and 1130.91.]
    • Terminal illness form should be reviewed and recertified in a timely manner. [Please refer to 55 Pa. Code§ 1101.51 (e)(1 )(x); and § 1130.22(1 )(ii)(2)(i)(ii)(B). See also 55 Pa. Code§§ 1130.21 (3), and 1130.91. for more information.]

• Medical record was missing the initial Certification of Terminal Illness form [in violation of 55 Pa. Code § 1101.51 (e) (1)(x); and 55 Pa. Code § 1130.22(1)(2)(5). See also 55 Pa. Code §§ 1130.21(3). 1130.71©, and 1130.91].

• Medical record had an untimely/missing Recertification of Terminal Illness form. The hospice must obtain written Recertification of Terminal Illness with two calendar days after beginning of each 60-day benefit period occurring subsequent to the initial 60-day period during which the recipient was admitted to hospice [in violation of 55 Pa. Code § 1101.51 (e)(1)(x); and 55 Pa. Code § 1130.22(3). See also 55 Pa. Code §§ 1130.21 (3) and 1130.91].

• Hospice related services or medications should not be supplied by another provider while the member is enrolled in hospice. [Please refer to 55 Pa. Code §§ 1130.52 (a)(1)(b), 1130.61(1)(4), and 1130.62 (8). See also 55 Pa. Code § 1130.91 and MA Bulletin 37-02-01 for more information.]

• Codes G0155 and G0299 were submitted as a claim with dates of services provided outside of the last 7 days of the recipient’s life. Please refer to [55 Pa. Code § 1101.75(a)(4)(6)(8). See MA Bulletin 06-15-02, effective date January 1, 2016. See also 55 Pa. Code § 1130.91].

If you have any questions, please contact the Provider Services Helpline at 1-888-991-9023 from Monday-Friday 9:00a.m. to 5:30p.m.