Ind. IHCP Hospice Services Provider Reference Module, Section 4, Option 1

The hospice provider (Hospice A) can discharge the hospice patient from the hospice program and make

arrangements in advance for the admitting date of the second hospice (Hospice B). If both providers are in

Indiana, this step does not require a contract between the two hospices, because this would be treated as a

discharge or transfer:

• Hospice A must complete the following forms, located on the Forms page at

in.gov/medicaid/providers, and submit them to the IHCP FFS PA-UM contractor:

➢ Medicaid Hospice Discharge form – The provider should note on the form that the member is

moving out of the service area, and specify which hospice is assuming the care during the short

absence.

➢ Hospice Provider Change Request Between Indiana Hospice Providers form – The patient or the

patient’s guardian must sign the completed form to indicate that they understand that it is to

change hospice providers and not a revocation of their hospice benefit.

➢ IHCP Prior Authorization Revision Request Form – This form is required only for faxed

submissions; it not required if the preceding two forms are submitted as an authorization

revision within the FFS PA-UM provider portal.

• Hospice B must also submit paperwork to the IHCP FFS PA-UM contractor to ensure authorization

of hospice care under its provider number. Hospice B should submit the following forms, all located

on the Forms page at in.gov/medicaid/providers:

➢ Medicaid Hospice Election form (State Form 48737 [R2/1-12]) (or, for dually eligible members

residing in a nursing facility, the Hospice Authorization Notice for Dually Eligible

Medicare/Medicaid Nursing Facility Residents form [State Form 51098 [3-03]/OMPP 0014]

and the hospice agency Medicare election form with the member’s name, date of birth and

Medicaid Member ID indicated)

➢ Medicaid Hospice Physician Certification form (not required for dually eligible members)

➢ Medicaid Hospice Plan of Care form (not required for dually eligible members)

➢ IHCP Prior Authorization Request Form – This form is required only for faxed submissions; it

not required if the preceding forms are submitted as an authorization request within the FFS

PA-UM provider portal.

Note: It is helpful if Hospice B also submits a copy of the Hospice Provider Change Request

Between Indiana Hospice Providers form.

It is important to note that the IHCP does not authorize or reimburse out-of-state hospice providers for

hospice care. Hospice agencies should not use option 1 when setting up a short out-of-state absence, as it

puts patients in a situation where they do not have IHCP hospice coverage. Option 2, noted in the following

section, should be used in these circumstances.