Three Compliance Clocks - All Start at Election Effective Date (Day 0)
Day 0 = Election effective date. Count calendar days, including weekends and federal holidays. The MAC must accept the NOE by Day 5. Submission alone is not sufficient if the NOE is rejected and resubmitted after Day 5.
Day 0 - Election
Election statement signed and effective date established. NOE preparation begins immediately.
42 CFR 418.24(b),(e)
Day 0–2 (if needed)
Obtain oral certification if written certification cannot be completed before benefit period begins. Document who provided it.
42 CFR 418.22(a)(3)(i)
Within 48 hours
RN initial assessment completed at location of service delivery. Patient rights delivered and acknowledged before any care is furnished.
42 CFR 418.54(a); 42 CFR 418.52(a)
Within 5 calendar days
NOE accepted by MAC. IDG comprehensive assessment completed (all 7 required domains). POC established before care is provided.
42 CFR 418.24(e); 418.54(b); 418.56(b)
Every 15 days (ongoing)
Comprehensive assessment updated. Plan-of-care reviewed by IDG. Both occur concurrently at same 15-day interval.
42 CFR 418.54(c); 418.56(c)
Certification Timing Quick Rules
| Rule | Requirement | Authority |
|---|
| Written certification | Must be obtained before claim submission | 42 CFR 418.22(a)(1) |
| Oral exception | Within 2 calendar days of period start if written not obtained in time | 42 CFR 418.22(a)(3)(i) |
| Early completion limit | No more than 15 calendar days before benefit period start date | 42 CFR 418.22(a)(3)(ii) |
| 1st period - who signs | Hospice physician or designee + attending physician (if patient has one) | 42 CFR 418.22(a)(1) |
| 2nd+ periods - who signs | Hospice physician or designee only | 42 CFR 418.22(a)(2) |
| F2F encounter (3rd+ period) | Within 30 days before recertification period start; attestation with signature and date | 42 CFR 418.22(a)(4),(b)(4) |
NOE Provider-Liable Day Rules
Late NOE = Provider-liable days. If the hospice does not file timely, Medicare will not pay for days from the election effective date to the date the NOE is accepted. The hospice cannot bill the beneficiary for these days. There is no recovery without a documented exception.
| Scenario | Consequence | Authority |
|---|
| NOE accepted by MAC by Day 5 | Full coverage from election effective date | 42 CFR 418.24(e) |
| NOE accepted after Day 5, valid exception documented | Exception may recover coverage. Specific exception categories required. | Claims Manual Pub. 100-04, Ch. 11 §20.1.1 |
| NOE accepted after Day 5, no documented exception | Provider-liable for all days from election through accepted NOE date; no recovery path | Claims Manual Pub. 100-04, Ch. 11 §20.1.1 |