Ind. IHCP Hospice Services Provider Reference Module, Section 5, Documentation Requirements for Hospice Members Residing in a Nursing Facility

For hospice members residing in a nursing facility, the IHCP, like the Medicare hospice program, requires

hospice providers to coordinate on a regular basis with the nursing facility provider. To ensure that the

IHCP member’s enrollment in the IHCP hospice benefit is clear to both hospice and nursing facility staff,

and compliant with medical records standards, the hospice provider must furnish the nursing facility staff

with the applicable Medicaid hospice forms to include in the member’s chart.

For billing purposes, the hospice provider must inform the nursing facility billing department of the dates

of the hospice election, revocation, discharge and change in hospice providers. It is the hospice provider’s

responsibility to develop the coordination procedures.

The following forms must be placed in the IHCP member’s nursing facility clinical record to clarify patient

care and reimbursement issues:

• For the Medicaid-only hospice member:

➢ Medicaid Hospice Election form (State Form 48737 [R2/1-12]) with the hospice authorization

stamp from the PA-UM contractor

➢ Medicaid Hospice Physician Certification form (State Form 48736 [R2/12-02]/OMPP 0006)

➢ Medicaid Hospice Plan of Care form (State Form 48731 [R2/11-04]/OMPP 0011)

➢ Coordinated plan of care prepared by the nursing facility and the hospice providers

• For the dually eligible (Medicare and Medicaid) hospice member:

➢ Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility Residents

form (State Form 51098 [3-03]/OMPP 0014)

➢ Hospice agency’s Medicare election form

➢ Coordinated plan of care prepared by the nursing facility and the hospice providers

• Medicaid Hospice Revocation form (State Form 48735 [4-98]/OMPP 0007)

• Medicaid Hospice Discharge form (State Form 48734 [R/12-02]/OMPP 0008)

• Hospice Provider Change Request Between Indiana Hospice Providers form (State Form 48733

[R/12-02] OMPP 0009)

• Change in Status of Medicaid Hospice Patient form (State Form 48732 [4-98]/OMPP 0010)

See Section 7: IHCP Recoupment for information regarding quarterly recoupment for nursing facility hospice

providers.