Ind. IHCP Hospice Services Provider Reference Module, Section 5, Certification for Medicaid-Only Hospice Members

The Medicaid Hospice Physician Certification form is used to certify that a member is terminally ill, with a

prognosis of six months or less. This form is available on the Forms page at in.gov/medicaid/providers.

Note: The IHCP requires hospice providers to use the IHCP hospice forms to enroll the

Medicaid-only member in the IHCP hospice benefit. No other forms are accepted in

lieu of the IHCP hospice forms for Medicaid-only hospice members. This policy

also applies to a Medicaid-only member who has private insurance (that may or may

not cover hospice care), but who is not enrolled in the Medicare hospice benefit.

Enrollment in the IHCP hospice benefit ensures that the IHCP covers, as the payer of

last resort, any hospice services not covered by a Medicaid-only member’s private

insurance.

According to 42 CFR 418.22, for the initial 90-day hospice benefit period, the Medicaid Hospice Physician

Certification form must be signed by both the following:

• The medical director of the hospice or the physician member of the hospice interdisciplinary team

• The attending physician (if the individual has an attending physician)

For this initial period, the hospice must submit one physician certification form with both signatures to

the IHCP PA-UM contractor as proper medical documentation. To expedite the process, the IHCP

FFS PA-UM contractor accepts the physician certification form with a faxed signature of the member’s

attending physician. (The hospice provider faxes the form to the member’s attending physician, who then

signs the form and faxes it back to the hospice provider to submit to the PA-UM contractor along with all

other required documentation.) For cases when the member has no attending physician, the hospice

provider must specify this in the box where the attending physician’s signature is otherwise required.

For subsequent benefit periods, only the hospice medical director or the physician member of the hospice

interdisciplinary team must sign the physician certification.

The following certification rules apply to the hospice benefit periods:

• The signed and dated Medicaid Hospice Physician Certification form must identify the diagnosis

that prompted the client to elect hospice and must include a statement that the prognosis is six

months of life or less. Section C of the form must include sufficient information to support a

terminal condition. The physician signature alone is not sufficient to constitute a valid physician

certification and results in suspension of the request until corrected forms are submitted.

• For Period I, the hospice provider must submit to the FFS PA-UM contractor a written certification

statement and a plan of care signed by the appropriate medical personnel, within 10 business days

from the member’s election effective date:

➢ Hospice providers are reminded that the Medicaid Hospice Physician Certification form for the

first period must include the signature of the attending physician (if the member has one) in

addition to the signature of the hospice medical director or the physician member of the hospice

interdisciplinary team.

➢ The Medicaid Hospice Plan of Care form must be signed by the hospice medical director and

any of the two other disciplines listed on the form. See the Hospice Plan of Care Documentation

Requirements section for more information about the plan of care.

If the required signatures are not on the IHCP forms, the hospice analyst suspends the hospice

authorization paperwork for correction by the hospice provider.

• For Periods II and III, the hospice provider must submit to the FFS PA-UM contractor, within

10 business days, a written recertification (on the Medicaid Hospice Physician Certification form)

and an updated plan of care (on the Medicaid Hospice Plan of Care form) prepared and signed by

the appropriate medical personnel. If the required signatures are not on the IHCP forms, the hospice

analyst suspends the hospice authorization paperwork for correction by the hospice provider.

• Exceptions to the 10-business-day time frame for hospice authorization paperwork, required for

each of the hospice benefit periods, include IHCP-pending individuals or IHCP hospice members

residing in a nursing facility for whom CoreMMIS does not reflect a nursing facility level of care

(LOC).

If the preceding requirements are not met, payment cannot be made for services rendered for that benefit

period, because the hospice authorization process cannot be completed and no level of approval has been

provided.

The certification forms can be submitted via the FFS PA-UM contractor’s provider portal or by mail or fax,

as described in the Hospice Authorization Process section.

When the forms are received, the hospice analyst reviews the information submitted and takes the

appropriate action:

• If the certification forms are complete and approved, the hospice analyst authorizes the hospice

services for the requested benefit period. The hospice provider receives a n Indiana Medicaid Prior

Authorization Notification (PA notification letter) with a hospice effective date and the hospice

analyst’s name. The PA notification letter is the hospice provider’s notification that claims can be

submitted for that benefit period. Additionally, the IHCP Eligibility Verification System (on the

IHCP Provider Healthcare Portal [IHCP Portal], phone-based virtual assistant [GABBY] or 270/271

electronic transaction) will be updated to show a “Hospice Program” LOC for the member.

• If the forms are incomplete, the hospice analyst suspends the request and sends a letter asking the

hospice to resubmit a copy of that form with the corrected information.

• If the hospice analyst determines that the member does not qualify for the service (for example, due

to lack of medical necessity), the request is denied.

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

questions about form completion. See the IHCP Quick Reference Guide for contact information.