Ind. IHCP Hospice Services Provider Reference Module, Section 6, Dually Eligible Hospice Member in a Nursing Facility Becomes Medicaid-Only

The following example provides guidelines for the completion of the institutional claim (UB-04 claim form

or electronic equivalent) for this scenario. The hospice provider must complete the Change in Status of

Medicaid Hospice Patient form to inform the IHCP that the individual is no longer Medicare-eligible. The

hospice provider must submit the Change in Status of Medicaid Hospice Patient form to the FFS PA-UM

contractor or the appropriate MCE. The hospice forms are available on the Forms page at

in.gov/medicaid/providers.

For this example, July 15 is the date the member is eligible for Traditional Medicaid only. The hospice

provider plans to bill the IHCP for the entire month of July.

• From July 1 through July 14, the hospice member is dually eligible for Medicare and Traditional

Medicaid, so the hospice provider must bill the IHCP using revenue code 659 for the additional

room and board per diem for these dates of service. The hospice provider must bill Medicare for the

hospice services.

• From July 15 through July 31, the hospice member is eligible for Traditional Medicaid only, so the

hospice provider must bill the IHCP for the hospice services and the additional room and board

per diem for these dates of service. The hospice provider must use revenue codes 650 or 658 for

those dates of service. Revenue codes 650 and 658 include the additional room and board per diem

to cover costs incurred by the contracted nursing facility.