Ind. IHCP Hospice Services Provider Reference Module, Section 5, Hospice Authorization Process

Specific criteria pertaining to prior authorization (PA) for hospice services may be found in

405 IAC 5-34-4. The PA information that follows is a guideline for determining procedures for hospice

services requiring PA; however, see the Indiana Administrative Code (IAC) as the primary reference.

Note: IHCP-covered services that are not related to the hospice member’s terminal

condition are subject to the same established PA requirements as apply for

nonhospice members. For general information about requesting IHCP prior

authorization, see the Prior Authorization module.

When requesting FFS hospice services for Traditional Medicaid members, hospice providers must

complete the Indiana Health Coverage Programs Prior Authorization Request Form or submit an

authorization request via the FFS PA-UM provider portal, as described in the Submitting Hospice

Authorization Requests section. All applicable forms, available in the Hospice Forms section of the Forms

page at in.gov/medicaid/providers, must be submitted with the request, as follows:

• For Medicaid-only members, the following forms must be completed and attached to the PA

request:

➢ Medicaid Hospice Election form – Indicates the IHCP member’s willingness to choose the

service

➢ Medicaid Hospice Physician Certification form – Indicates the hospice member’s prognosis and

diagnosis that prompted hospice election

➢ Medicaid Hospice Plan of Care form – Monitors treatment modalities and processes

• For dually eligible (Medicare and Medicaid) members residing in a nursing facility, the following

forms must be completed and attached to the PA request:

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

form

➢ A copy of the hospice agency form showing the Medicare hospice election date (labeled with the

member’s name, date of birth and Medicaid Member ID)

The Indiana Health Coverage Programs Prior Authorization Request Form serves as a cover sheet for all

hospice authorization requests submitted by mail or fax. This form can be found in the Prior Authorization

section of the Forms page at in.gov/medicaid/providers. When submitting the request via the FFS PA-UM

contractor’s provider portal, the forms can be uploaded as attachments. If the forms are not uploaded along

with the portal request, but instead sent separately by fax or by mail, the Prior Authorization System

Revision Request Form should be used as a cover sheet for the attachments.

Supporting documentation must also be submitted as required. The IHCP allows electronic signatures

on supporting documents submitted with PA requests for home health and hospice services. An original

signature or signature stamp is still required on the Indiana Health Coverage Programs Prior Authorization

Request Form, as well as on all Indiana state forms submitted as attachments to the request, including the

Medicaid Hospice Election form, the Medicaid Hospice Physician Certification form, the Medicaid

Hospice Plan of Care form and the Hospice Authorization Notice for Dually Eligible Medicare/Medicaid

Nursing Facility Residents form.

Note: The IHCP recommends that hospice providers keep all IHCP hospice forms that

reflect the original signature of the required parties and submit copies of these forms

with the PA request. IHCP forms with original signatures are legal documents that

reflect the member’s enrollment in the IHCP hospice benefit and must be kept in the

hospice member’s clinical chart.

For approval of the hospice benefit, the hospice provider must submit documentation to the IHCP FFS

PA-UM contactor within 10 business days of the member’s election effective date, and for each benefit

period. The hospice analyst reviews the documentation for accuracy and completeness to authorize services

for the requested period.

To facilitate paperwork for hospice providers and to minimize the possibility of auto-enrollment of hospice

members between hospice benefit periods, the following policies are in effect:

• The hospice provider may submit the completed Medicaid Hospice Physician Certification form

and Medicaid Hospice Plan of Care form to the IHCP FFS PA-UM contactor (either by fax or

uploaded as attachments to an authorization revision on the FFS PA-UM provider portal) two weeks

before the start date of the recertification period.

• The hospice provider must assume responsibility for properly completing and submitting the

appropriate forms. Missing or incomplete forms will result in the request being suspended for

additional information.

Hospice providers are required to use hospice revenue code 651 on all FFS hospice authorization

requests. The hospice authorization enables reimbursement at all IHCP hospice levels of service.

See Table 5 for instructions on completing the Indiana Health Coverage Programs Prior Authorization

Request Form for FFS hospice requests sent by mail or fax. See the Education and Training page at

inmedicaidffs.acentra.com to download the Hospice PA Step-by-Step instructions on submitting the

hospice PA request via the FFS PA-UM provider portal.

Note: For instructions on submitting hospice authorization requests for managed care

members, contact the member’s MCE. See the IHCP Quick Reference Guide for

contact information.

Table 5 – Indiana Health Coverage Programs Prior Authorization Request Form

Completion Instructions for FFS Hospice Requests Sent by Mail or Fax

Field Description

Check the box of the entity that

must authorize the service.

Select the option for the Fee-for-Service PA-UM entity.

Patient Information:

• IHCP Member ID

• Date of Birth

• Patient Name

• Address

• City/State/ZIP Code

• Patient/Guardian Phone

• PMP Name

• PMP NPI

• PMP Phone

Enter the information requested for the member who is to receive the

requested service. Required.

Enter the information requested for the member’s primary medical

provider (PMP), including National Provider Identifier (NPI).

Required, if applicable.

Requesting Provider

Information:

• Requesting Provider

NPI/ Provider ID

• Taxonomy

• Taxpayer Identification

Number (TIN)

• Provider Name

• Provider Address

Enter the information requested for each field. Required.

Requesting medical providers should enter their National Provider

Identifier (NPI). Atypical providers should enter their IHCP-issued

Provider ID.

The requesting provider NPI/Provider ID must be the billing NPI/Provider

ID used by the provider or entity requesting the authorization:

• For a group/corporate entity, the requesting provider

NPI/Provider ID is different from the rendering provider

NPI/Provider ID.

• For a sole proprietor, the requesting provider NPI/Provider ID

and the rendering provider NPI/Provider ID will be the same.

• For a dual-status provider, the requesting provider

NPI/Provider ID and the rendering provider NPI/Provider ID

may or may not be the same.

A valid NPI or Provider ID is required. If the requesting provider is not

enrolled in the IHCP, the PA request will not be entered and the FFS

PA-UM contractor will notify the requesting provider by telephone.

The provider’s copy of the Indiana Medicaid Prior Authorization

Notification (PA notification letter) is sent to the mail-to address on file

for the requesting provider’s NPI and Provider ID combination.

Rendering Provider Information Leave blank.

Preparer’s Information Leave blank.

Ordering, Prescribing or

Referring (OPR) Provider

Information

Leave blank.

Medical Diagnosis Leave blank.

Assignment Category Make a checkmark in the Hospice box.

Dates of Service, Start Enter the requested start date for the hospice benefit period.

(For continued services, the start date must be the day after the previous

end date.)

Dates of Service, Stop Enter the requested end date of the hospice benefit period.

Procedure/Service Codes Enter hospice revenue code 651 only. Required.

Field Description

If any other revenue code is used, the FFS PA-UM contactor will return

the request to the provider for correction.

Modifiers Leave blank.

Service Description Enter the word hospice.

Taxonomy Leave blank.

Place of Service (POS) Leave blank.

Units Leave blank.

Dollars Leave blank.

Notes Leave this section blank.

Hospice analysts refer to other submitted documentation (such as the

hospice election form, the physician certification form and the plan of

care) for required hospice authorization information.

Signature of Qualified

Practitioner

Date

Authorized provider, as listed in the Provider Types Allowed to Submit PA

Requests section of the Prior Authorization module, must sign and date

the form. Signature stamps can be used. Required.

Note: Electronic signatures are not acceptable on this form.