Ind. IHCP Hospice Services Provider Reference Module, Section 5, Certification for Dually Eligible Hospice Members Residing in Nursing Facilities

Because the Part A Medicare Administrative Contractor (MAC) determines medical necessity for hospice

care, the IHCP has opted to change the documentation requirements for IHCP hospice authorizations for

members residing in nursing facilities, for whom the IHCP pays for room-and-board services, as specified

in 405 IAC 1-16-4, and for whom Medicare pays for the hospice services. For these members, a one-page

notification sheet, Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility

Residents (available on the Forms page at in.gov/medicaid/providers), permits the IHCP PA-UM contactor

to enter the hospice authorization without evaluating medical necessity.

To ensure authorization, the provider must provide the information in each box of the notification form and

confirm that the form is signed by the primary hospice nurse. Blank boxes are not permissible. If a

particular box does not apply, simply type not applicable or NA. Failure to properly complete the form

results in suspension of the request and instructions for the provider to correct and resubmit the form.

A copy of the hospice agency form showing the Medicare hospice election date should be submitted with

the Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility Residents form.

The IHCP requests that providers indicate the member’s name, date of birth and Medicaid Member ID on

the copy of the Medicare hospice election form submitted to the IHCP.

These documents should be submitted to the appropriate PA-UM contractor as described in the Hospice

Authorization Process section. If the documentation is complete and correct, the hospice analyst authorizes

the hospice services for the requested benefit period. The hospice provider receives a prior authorization

notice with a hospice effective date and the hospice analyst’s name. The prior authorization notice is the

hospice provider’s notification that claims can be submitted for that benefit pe riod.

Hospice providers can contact the PA-UM contactor to speak to a hospice reviewer if they have any

questions about form completion. For contact information, see the IHCP Quick Reference Guide.