5CFNP: No Plan of Care Submitted

The claim has been fully or partially denied as the documentation submitted for review did not include a valid plan of care for all or some of the dates billed.

For a beneficiary to receive hospice care covered by Medicare, a plan of care (POC) must be established before services are provided. The POC is developed from the initial assessment and comprehensive assessment and services provided must be consistent with the POC.

How to Prevent This Denial

• The POC must contain certain information to be considered valid. This includes:
  • Scope and frequency of services to meet the beneficiary's/family's needs
  • Beneficiary-specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief
  • Services that are reasonable and necessary for the palliation and management of the beneficiary's terminal illness and related conditions
• The plan of care must be reviewed, revised and documented as frequently as the beneficiary's condition requires, but no less frequently than every 15 calendar days

Resources

• Change Request 6982
• Code of Federal Regulations, 42 CFR – Section 418.56 and 418.200
• CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4
• Responding to a Hospice Additional Documentation Request (ADR)