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

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 necessary paperwork to

enroll the Medicaid-only hospice member in the Medicare hospice benefit once the individual is Medicare

eligible. The hospice provider must also submit the Change in Status of Medicaid Hospice Patient form

(State Form 48732 [4-98]/OMPP 0010) to the Medicaid PA-UM contractor to inform the IHCP that the

member is Medicare eligible.

In this example, July 15 is the date the individual is considered dually eligible (Medicare and Medicaid) for

billing purposes by both programs. The hospice provider plans to bill IHCP for the entire month of July

using the following calculations:

• From July 1 to July 14, the hospice member was a Medicaid-only member so the hospice provider

must bill IHCP using 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.

• From July 15 to July 31, the hospice member is considered dually eligible, and the hospice provider

must bill the IHCP using revenue code 659 for the additional room and board per diem for those

dates of service. The hospice provider must bill Medicare for the hospice services.