Ind. IHCP Hospice Services Provider Reference Module, Section 6, IHCP Reimbursement Policy

This section clarifies the IHCP reimbursement policy and process for billing Medicaid hospice claims when

a member has private insurance, Medicare hospice, and Medicaid room and board; and the process for

billing Medicaid hospice claims when the member has private insurance and Medicaid.

It is not mandatory for nursing facility providers to reserve beds; however, the FSSA continues to reimburse

hospice providers at one-half the nursing facility case-mix reimbursement rate for reserving nursing facility

beds for hospice members, when the occupancy criteria are met as set forth in 405 IAC 5-34-12.

It is the hospice agency’s responsibility to confirm the nursing facility occupancy percentage on the date that

the leave of absence begins. Hospice providers can bill the IHCP for leave days only when the nursing facility

occupancy percentage is at 90% or greater on the day the leave begins. If the nursing facility occupancy

percentage falls below 90% following the date the leave began, the hospice provider can continue to bill the

50% of the nursing facility’s case-mix reimbursement rate for the entire hospital or therapeutic leave.

When the nursing facility occupancy is below 90% on the date the leave of absence begins, the hospice

agency should use revenue code 180 to bill the IHCP for leave days. Revenue code 180 is a nonpaid

revenue code used to generate an IHCP denial, and it can be used when charging a resident or legal

guardian for nonreimbursed bed-hold days.

The explanation of benefits (EOB) detail for revenue code 180 lists the claim as denied, with EOB code

4215 – Leave days not a covered service for this bill type – nursing facility occupancy less than 90%. A

member who receives hospice services and resides in a nursing facility has dual eligibility, the hospice

provider must bill claims to the IHCP using revenue code 659 (room and board for dually eligible nursing

facility hospice members only). A member is considered dually eligible if enrolled in both Medicare and

Medicaid. The member may also have other commercial insurance.

When verifying member eligibility, members who are dually eligible will be listed as having both Qualified

Medicare Beneficiary coverage and also Full Medicaid or Package A – Standard Plan coverage. These

members are referred to as QMB-Also.

When an IHCP member who receives hospice services and resides in a nursing facility is not dually eligible

(not a QMB), the hospice provider must bill claims to the IHCP using revenue code 65 0 (for routine home

hospice care delivered in a nursing facility) or 658 (for continuous home hospice care delivered in a nursing

facility). The provider must use revenue code 650 or 658 even if the member has other commercial

insurance and Medicaid.

If other insurance pays for the hospice care services in full, the hospice provider shall only receive payment

from the IHCP for room-and-board services.

Note: CoreMMIS automatically deducts the patient liability when third-party liability

payment is received.