Referral-to-Admission Workflow

Role-mapped steps aligned to Medicare regulatory requirements

Hospice CoP Training

Educational Use Only

Phase 1 - Referral Intake (Intake Coordinator)

Step	Action	Regulatory Link
1.1	Receive referral; log timestamp and source; capture patient name, DOB, location, contact, referring provider	Operational - creates audit trail
1.2	Confirm Medicare Part A eligibility (HIC number, coverage period, traditional vs. MA)	42 CFR 418.20
1.3	Identify primary terminal diagnosis; obtain clinical records (H&P, discharge summary)	42 CFR 418.22(b) - cert narrative support
1.4	Classify: (a) eligible - proceed; (b) MA - escalate; (c) insufficient info - request records before sending clinician	42 CFR 418.20; 418.22

Phase 2 - Admission Evaluation (RN + Medical Director)

Step	Action	Regulatory Link
2.1	On-site evaluation: clinical status, function, symptom burden, environment, caregiver capacity, medication list	42 CFR 418.22(b)(3); 418.54(b)
2.2	Assess prognosis vs. 6-month standard; escalate to medical director if unclear	42 CFR 418.3; 418.22(b)(1)
2.3	Medical director provides formal recommendation to admit or not admit - documented in record	42 CFR 418.25

Phase 3 - Election & Certification (RN / SW / MD / Intake)

Step	Action	Regulatory Link
3.1	Discuss hospice benefit: palliative nature, waiver of curative services, attending physician selection, BFCC-QIO	42 CFR 418.24(b)
3.2	Execute election statement: verify all elements; effective date ≥ signature date	42 CFR 418.24(b),(e)
3.3	Initiate addendum process if non-covered items identified	42 CFR 418.24(c)–(d)
3.4	Execute certification: patient-specific narrative; correct signatory for benefit period	42 CFR 418.22(b); 418.22(a)(1)
3.5	F2F attestation (3rd+ periods): hospice physician or NP; encounter date + signature + signature date	42 CFR 418.22(a)(4); FY 2026
3.6	Submit NOE to MAC - target same-day; confirm acceptance by Day 5	42 CFR 418.24(e)

Phase 4 - Initial Assessment (RN) & Phase 5 - IDG Comprehensive Assessment

Step	Action	Regulatory Link
4.1	Schedule initial assessment for Day 0 or Day 1 - never past 48-hour window	42 CFR 418.54(a); SOM L522
4.2	At start of visit, before any clinical task: deliver patient rights verbally + in writing; obtain signature	42 CFR 418.52(a)
4.3	Complete initial assessment: immediate needs, symptoms, safety, caregiver, medications, urgent interventions	42 CFR 418.54(a); SOM L524, L525
4.4	Notify IDG; assign all 7 domain leads; schedule comprehensive assessment completion by Day 5	42 CFR 418.54(b); 418.56(a)
5.1	IDG completes all 7 domains by Day 5 (physical, psychosocial, emotional, spiritual, drug, bereavement, safety)	42 CFR 418.54(b)(1)–(7)
5.3	Develop individualized POC from assessment findings; attending physician review and sign	42 CFR 418.56(b); MBPM
5.5	File signed POC, assessment, election statement, certification, NOE confirmation, and rights acknowledgement	42 CFR 418.104(b); SOM L673–L676

Record Completeness = Payment Eligibility. Signed election statement + certified terminal illness + completed POC + patient rights acknowledgement must all be in the clinical record before or at claim submission. The record is the claim.

Educational Use Only. Not legal advice. Verify against current primary sources and your organization's policies.