Ind. IHCP Hospice Services Provider Reference Module, Section 5, Request for Home Health Service Reimbursement in Addition to the Hospice Per Diem

The IHCP has directed that a member age 21 or older who is enrolled in the IHCP hospice benefit cannot

concurrently receive IHCP home health services (outside those that are reimbursed under the hospice per

diem) for treatment of the terminal diagnosis or related conditions. This IHCP policy is consistent with

Medicare program guidelines. IHCP members age 21 or older must determine which services best meets

their needs.

The PA-UM contractor denies requests for home health hours for treatment of an IHCP hospice member’s

terminal illness that is duplicative of hospice care.

If the PA-UM contractor receives a request for additional home health hours for treatment of the nonterminal

condition, the request must fulfill all the requirements in 405 IAC 5-3-5. The following criteria must clearly

appear on the written PA request to ensure that the request is not suspended for additional information:

• Written diagnosis and ICD code for the terminal and the nonterminal illness required

• Thorough explanation of the medical necessity that clearly documents that there is no relationship

between the terminal illness and the required or requested home health treatments outlined in the PA

request

The IHCP has the same standards as the Medicare hospice program, in that each provider must thoroughly

document that there is no relationship between the terminal illness and the required home health treatments.

If the IHCP determines during a postpayment review that the services are related, the hospice provider is

liable for all services rendered.

It is important to note that the hospice provider must submit both the hospice plan of care and the home

health plan of care to the PA-UM contractor to ensure a comprehensive review.

A member age 20 or younger who elects hospice care may receive concurrent curative treatment in

conjunction with hospice services for the terminal illness. This provision allows the member or member’s

representative to elect the hospice benefit when the need for hospice care is certified by a physician,

without forgoing any curative service to which the child is entitled under Medicaid for treatment of the

terminal condition.

Note: If a provider has prior authorization and the claim denies for recipient being

ineligible, the provider needs to work with a Provider Relations field consultant.