Ind. IHCP Hospice Services Provider Reference Module, Section 4, Option 2

This option allows IHCP hospice providers to contract with non-IHCP-enrolled hospice providers,

including out-of-state hospice providers, when a patient will be living outside of the hospice’s service area

for a short period. In these situations, the hospice authorization continues under the hospice provider that

submitted the original authorization request to the IHCP FFS PA-UM contractor (Hospice A), and the

claims continue to be billed by Hospice A, which will then, in turn, pass the reimbursement on to the

subcontracting hospice provider (Hospice B).

Follow these steps:

1. Hospice A (the contracting hospice) must submit an authorization revision request to the FFS

PA-UM contractor, along with a completed Change in Status of Medicaid Hospice Patient form

(State Form 48732 [4-98]/OMPP 0010), located on the Forms page at in.gov/medicaid/providers.

➢ Within the authorization revision request, the hospice should state that it is contracting with

another hospice to provide care during this short absence.

➢ On the Change of Status form, Hospice A’s information should be entered in Section B:

Provider Information. In Section C(C), Hospice A’s information should be entered in the

FROM: OLD Institutional Care Setting fields, and Hospice B’s information should be entered in

the TO: NEW Institutional Care Setting fields.

2. Hospice A (the contracting hospice) is responsible for submitting claims for services provided by

Hospice B (the subcontracted hospice), as well as for submitting required paperwork each benefit

period so there is no break in hospice coverage.

3. When the member returns from the short absence, Hospice A should submit another Change in

Status of Medicaid Hospice Patient form, notifying the FFS PA-UM contractor of the patient’s

return.

Hospice A (the contracting hospice) does incur a liability while transporting the patient to the subcontracted

hospice, so it is important that all liabilities be addressed by an attorney.