Ind. IHCP Hospice Services Provider Reference Module, Section 5, Prior Authorization for Treatment of Nonterminal Conditions

Except as described in the following paragraph, prior authorization (PA) is required for any IHCP-covered

service not related to the hospice member’s terminal condition. The IHCP provider billing for the treatment

of the nonterminal condition is responsible for obtaining the PA. A written PA request for treatment of the

nonterminal condition must fulfill all the requirements specified in 405 IAC 5-3-5. For more information

about IHCP PA, see the Prior Authorization module.

Notwithstanding any other provision under this section, PA is not required for the following services when

provided to hospice patients:

• Pharmacy services for conditions not related to the patient’s terminal condition, except as described

in the following note. Pharmacy services related to the patient’s terminal condition are included in

the hospice per diem.

Note: A prescriber’s indication of brand medically necessary for a prescribed drug requires

PA. This means that, if a prescriber chooses to specify brand medically necessary for

a drug, PA must be obtained for the brand name drug before the pharmacist can be

paid for the brand name drug. This action implements 405 IAC 5-24-8.

• Dental services

• Vision care services

• For IHCP-enrolled hospice members age 20 or younger – curative care services that do not

otherwise require PA, as described in the Billing and Reimbursement for Concurrent Hospice and

Curative Care for Children section

Note: The PA-UM contractor must review requests for payment of services outside the per

diem rates established within the context of the plan of care on a case-by-case basis.

For information about coordinating and billing services to treat nonterminal conditions in IHCP hospice

members, see the Treatment for the Hospice Member’s Nonterminal Condition section.