Overview
This module translates the regulatory requirements from the prior five modules into an integrated, role-mapped operational workflow. Each step is linked to its governing authority so staff understand why each action is required — not just what to do.
The six workflow phases below align to the five compliance “hard stops” identified in the Program Overview. Every workflow decision gate represents either a payment-condition requirement or a CoP Phase I survey risk.
Phase 1 — Referral Intake
| Step | Role | Action | Regulatory Link |
|---|---|---|---|
| 1.1 | Intake coordinator | Receive referral (call, fax, EHR, verbal); log timestamp and source; capture: patient name, DOB, location, contact, referring provider identity | Operational — no specific Medicare form required; creates audit trail |
| 1.2 | Intake coordinator | Confirm Medicare Part A eligibility (verify HIC number, period of coverage, Medicare Advantage vs. traditional Medicare) | 42 CFR 418.20 — eligibility baseline |
| 1.3 | Intake coordinator | Identify primary terminal diagnosis and co-morbidities from referral source; obtain clinical records (H&P, discharge summary, recent labs) if not provided | 42 CFR 418.22(b) — certification narrative must be supported by clinical records |
| 1.4 | Intake coordinator | Classify referral: (a) Medicare-eligible / terminally ill — proceed; (b) Medicare Advantage — escalate to billing; (c) non-Medicare — identify other payer pathway; (d) insufficient clinical information — request records before sending clinician | 42 CFR 418.20; 418.22; Operational triage |
Medicare Advantage (MA) Triage
Patients enrolled in Medicare Advantage may have different election, NOE, and coverage mechanics than traditional Medicare. Confirm plan-specific rules before assuming traditional Medicare election/NOE deadlines apply.
Phase 2 — Admission Evaluation
| Step | Role | Action | Regulatory Link |
|---|---|---|---|
| 2.1 | RN or clinician evaluator | Conduct on-site evaluation: clinical status, function, symptom burden, environment, caregiver capacity; obtain current medication list for drug profile work | 42 CFR 418.22(b)(3) — supports narrative; 42 CFR 418.54(b) — domain 6 (drug profile) |
| 2.2 | RN evaluator / medical director | Assess prognosis relative to 6-month standard; consider primary and co-morbid diagnoses and current clinical trajectory; if prognosis unclear, escalate to medical director review before recommending admission | 42 CFR 418.3 (definition); 42 CFR 418.22(b)(1) |
| 2.3 | Medical director (or IDG physician designee) | Provide formal recommendation to admit or not admit to hospice — documented in the record before or at the time of admission; consult attending physician findings if available | 42 CFR 418.25 — admission by recommendation only |
| 2.4 | Admission coordinator | If admission is NOT recommended: document reason; provide BFCC-QIO contact and NOMNC if the patient is transitioning from another Medicare benefit (SNF, HH) to avoid liability | Operational; 42 CFR 418.52(a)(5) — notice of discharge/denial rights |
Phase 3 — Election and Certification Execution
| Step | Role | Action | Regulatory Link |
|---|---|---|---|
| 3.1 | RN or social worker | Discuss hospice benefit with patient and family: nature of palliative care, waiver of curative Medicare services for terminal illness, attending physician selection, cost-sharing, BFCC-QIO rights | 42 CFR 418.24(b) — election statement required elements; Oct 2020 disclosures |
| 3.2 | Intake coordinator / RN | Execute the election statement: verify all required elements present; confirm effective date = same day as signature or later (never earlier); witness or notate representative authority if representative is signing | 42 CFR 418.24(b),(e) |
| 3.3 | Intake coordinator | Initiate addendum process: if any non-covered items/services/drugs identified at intake, prepare addendum for execution within regulatory timeframe | 42 CFR 418.24(c)–(d) |
| 3.4 | Certification coordinator / medical director | Execute written certification: confirm certifying physician identity (1st period = MD/IDG physician + attending if one exists; 2nd+ = MD/IDG physician); obtain patient-specific narrative — do not use template language | 42 CFR 418.22(b); 418.22(a)(1) |
| 3.5 | Medical director (3rd+ period only) | Confirm F2F encounter was conducted by hospice physician or NP within 30 days before period start; ensure attestation contains encounter date, signature, and signature date | 42 CFR 418.22(a)(4),(b)(4); FY 2026 Final Rule |
| 3.6 | Intake coordinator | Submit NOE to MAC — target same-day submission; confirm acceptance within 5 calendar days from election effective date; document acceptance confirmation number/timestamp | 42 CFR 418.24(e); Claims Manual Ch. 11 §20.1.1 |
NOE Day-Count Rule
Day 0 = election effective date. Day 5 = last day for accepted NOE. Count calendar days, including weekends and federal holidays. MAC acceptance — not submission — must occur by day 5. Submit by end of business on Day 1 to create buffer for rejection and resubmission.
Phase 4 — Initial Assessment and Patient Rights
| Step | Role | Action | Regulatory Link |
|---|---|---|---|
| 4.1 | RN | Schedule initial assessment visit for Day 0 or Day 1 — never defer past the 48-hour deadline; document day and time of election effective date to confirm 48-hour window | 42 CFR 418.54(a); SOM Appendix M L522 |
| 4.2 | RN (at start of visit, before any clinical task) | Deliver patient rights verbally and in writing in the patient's primary language; obtain signed acknowledgement before beginning any nursing assessment or care | 42 CFR 418.52(a) — before furnishing care |
| 4.3 | RN | Complete initial assessment: document immediate needs, symptom severity (pain, dyspnea, nausea, anxiety, wound status), functional status, safety risks, caregiver capacity, medication inventory, and any urgent interventions | 42 CFR 418.54(a); SOM L524, L525 — not a social visit |
| 4.4 | RN | Notify other IDG members of patient election; assign domain ownership for comprehensive assessment; schedule IDG assessment to complete all domains by Day 5 | 42 CFR 418.54(b); 42 CFR 418.56(a) |
Phase 5 — IDG Comprehensive Assessment and Plan of Care
| Step | Role | Action | Regulatory Link |
|---|---|---|---|
| 5.1 | IDG (all disciplines) | Complete all 7 assessment domains by Day 5: physical (RN), psychosocial (SW), emotional (SW/RN), spiritual (chaplain), drug profile (RN/pharmacist), bereavement (SW/chaplain), safety/environment (RN/aide) | 42 CFR 418.54(b)(1)–(7); SOM L531–L537 |
| 5.2 | IDG care coordinator | Track completion of all 7 domains on a shared tracking tool; escalate any domain not completed by Day 4 to supervisor; document clinical basis for any deferral | QSO-23-08 emphasis; SOM L530 |
| 5.3 | IDG (collaborative) | Develop written plan of care from assessment findings: individualized goals, interventions, medication plan, physician orders, caregiver instructions, and anticipated frequency/level of service | 42 CFR 418.56(b); MBPM coverage requirement |
| 5.4 | Medical director / attending physician | Review and sign plan of care; attending physician participation documented if patient has one; attending cosignature obtained or formal process for concurrent care coordination initiated | 42 CFR 418.56(b); 418.25 |
| 5.5 | IDG coordinator | File signed POC, comprehensive assessment, election statement, certification, NOE acceptance confirmation, and signed patient rights acknowledgement in the clinical record before Day 5 or before claim submission, whichever is earlier | 42 CFR 418.104(b); SOM L673–L676 |
Record Completeness = Payment Eligibility
The clinical record is the claim. If the signed election statement, certified terminal illness, completed POC, and patient rights acknowledgement are not in the record, there is no documentation trail for the claim period. Surveyors and MAC reviewers start with the record, not the verbal assertion that things were done.
Phase 6 — Ongoing Cadence
| Action | Frequency | Responsible Role | Authority |
|---|---|---|---|
| Comprehensive assessment update | At least every 15 calendar days (more frequently if patient status changes) | IDG — RN leads; all domains reviewed | 42 CFR 418.54(c) |
| Plan-of-care review and update | At least every 15 calendar days (concurrent with assessment update) | IDG; attending involvement as appropriate | 42 CFR 418.56(c) |
| Recertification planning | Begin 20+ days before benefit period end | Medical director / certification coordinator | 42 CFR 418.22(a)(3)(ii) — no more than 15 days before period start |
| F2F tracking (3rd+ period) | Trigger 45 days before benefit period end to allow scheduling, completion, and attestation within 30-day window | Medical director / NP coordinator | 42 CFR 418.22(a)(4) |
| NOE for period changes / revocations | Same 5-day rule applies to new period elections after revocation or discharge | Intake / billing coordinator | 42 CFR 418.24(e) |
Role Responsibility Summary
| Role | Primary Admission Responsibilities |
|---|---|
| Intake coordinator | Eligibility check; referral classification; NOE submission and tracking; addendum initiation; clinical record compilation |
| RN evaluator / admissions RN | Prognosis evaluation support; initial assessment (sole responsible clinician, 48 hrs); patient rights delivery and signature; domain lead for physical assessment and drug profile |
| Medical director | Admission recommendation; certification narrative review and sign; F2F attestation (or NP attestation review); recertification planning |
| Social worker | Psychosocial, emotional, and bereavement domains; representative authority documentation; advance directive status; BFCC-QIO disclosure support |
| Chaplain | Spiritual domain; bereavement risk domain co-ownership |
| IDG coordinator / care coordinator | Domain completion tracking; Day 5 deadline management; record completeness before claim submission |
| Billing / compliance | NOE acceptance verification; late NOE exception documentation; benefit period tracking; F2F window flagging |
Educational Use Only
This workflow translates primary federal regulatory authorities into an operational model. It is not legal advice, and does not substitute for legal counsel, compliance review, or your organization's governing policies and procedures.
Knowledge Check
Referral-to-Admission Workflow
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