{"ref":"NC-HSP-ELC-03","title":"Revocation, Change of Designated Hospice and Change of Attending Physician","category":"Hospice care","summary":"Sets how a patient may revoke the hospice election, re-elect later, change the designated hospice once in each election period, or change the attending physician, using signed statements with the content federal rules require, the notices to Medicare and NC Medicaid that follow, and the rule that the Agency never asks or pressures a patient to revoke.","inShort":["Only the patient or representative can revoke. Never suggest or pressure a patient to revoke.","Listen to the reasons and tell the care coordinator the same day. Try to fix the problem.","Use Form NC-HSP-ELC-03-A. The effective date cannot be before the date it is signed.","A patient can change hospices once per benefit period. It is not a revocation (Form NC-HSP-ELC-03-B).","To change attending physician, the patient signs Form NC-HSP-ELC-03-C and the new physician must agree.","Tell billing right away: the Medicare notice is due within 5 calendar days."],"primaryCitation":"42 CFR §418.28","citations":["NC Medicaid Clinical Coverage Policy 3D, sections 5.6.5, 5.6.6, 5.9, 5.12.2, 5.12.3, 5.12.4","10A NCAC 13K .0601(3), (5)","10A NCAC 13K .0901(b)(16)"],"federalCitations":["42 CFR §418.24(h), (i)","42 CFR §418.28","42 CFR §418.30","42 CFR §418.104(e)","42 CFR §418.3"],"surveyorAsks":["Show me a revocation statement. Who signed it, and is the effective date on or after the date it was signed?","How do you make sure a patient is not encouraged to revoke?"],"forms":[{"ref":"NC-HSP-ELC-03-A","title":"Revocation of Hospice Election"},{"ref":"NC-HSP-ELC-03-B","title":"Change of Designated Hospice"},{"ref":"NC-HSP-ELC-03-C","title":"Change of Attending Physician"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §418.28)","5. Revocation","5.1 What revocation means for the patient","5.2 After a revocation","6. Re-Election","7. Change of Designated Hospice","8. Change of Attending Physician","9. Loss of NC Medicaid Eligibility","10. Responsibilities","11. Records and Compliance Monitoring","12. Staff Training","13. References","14. Related Policies and Forms","15. Approval","16. Revision History"],"version":"1.0","sample":false,"pack":"nc-hospice","state":"North Carolina","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}