Ind. IHCP Hospice Services Provider Reference Module, Section 7, Medical Records Review

The hospice provider is required to submit specific paperwork to the IHCP FFS prior authorization and

utilization management (PA-UM) contractor for each hospice benefit period to obtain IHCP hospice

authorization for those dates of service as described in Section 5: Hospice Authorization in this module.

The IHCP hospice forms are legal documents. Hospice providers must adhere to the same medical records

standards required for the completion of the hospice agency’s form. Hospice providers must use these

forms to document the medical necessity of the IHCP member’s hospice care.

It is the hospice provider’s responsibility to place the authorized hospice forms in the hospice member’s

medical chart at the hospice agency and at the contracted nursing facility. The inclusion of the IHCP

hospice forms in the nursing facility chart is important when a member elects, revokes or is discharged

from hospice care.

The hospice provider must have the forms listed in Table 9 available in the patient’s medical chart to

demonstrate compliance with IHCP hospice authorization (including for that benefit period) and IHCP

program compliance standards.

The IHCP hospice rule includes language specifying the forms required to be maintained by the hospice

agency or the contracted nursing facility. The hospice provider is required to keep all IHCP hospice forms

submitted or should have been submitted to the IHCP FFS PA-UM contractor. This documentation should

be kept in the hospice member’s clinical chart at the hospice agency. The IHCP also expects hospice

providers to include the same documentation in the hospice member’s clinical chart at the nursing facility.

Although the IHCP expects these forms to be in the member’s clinical chart, the review process does not

include any penalty if the forms are not located in the chart during the review. The hospice provider is

instructed in the summary of findings letter to correct the documentation discrepancy to ensure the hospice

member’s clinical records reflect accurate documentation of the member’s enrollment in the IHCP hospice

benefit.

Table 9 lists the IHCP documentation requirements for hospice providers to include in the patient’s clinical

record at the hospice agency both for Medicaid-only members and for those having dual eligibility with

Medicaid and Medicare.

Table 9 – Documentation Requirements for Hospice Providers

Form Description

Required for

Medicaid-Only

Member?

Required for

Dually Eligible

Member?

Hospice

Authorization Notice

for Dually Eligible

Medicare/Medicaid

Nursing Facility

Residents

(State Form 51098

[3-03]/OMPP 0014)

For dually eligible (Medicare and

Medicaid) hospice members residing

in nursing facilities, the IHCP requires

this one-page hospice authorization

notification along with the

corresponding hospice agency form

reflecting the Medicare hospice

election date.

No Yes, if residing in

nursing facility

Medicaid Hospice

Election

(State Form 48737

[R2/1-12])

This Medicaid hospice election form,

signed by the member (or member’s

representative), is required for all

IHCP members served by the hospice

with the exception of except for dually

eligible (Medicaid and Medicare)

members.

Yes No

Medicaid Hospice

Physician

Certification (State

Form 48736

[R/12-02]/OMPP

0006)

This hospice agency physician

certification form is required for the

state hospice survey process. This

requirement applies to all IHCP

members served by the hospice except

dually eligible (Medicaid and

Medicare) members.

Yes No

Medicaid Hospice

Plan of Care

(State Form 48731

[R2/11-04]/

OMPP 0011)

This form detailing the plan of care is

required for all IHCP members served

by the hospice except dually eligible

(Medicaid and Medicare) members.

The plan of care should be updated to

reflect appropriate changes in the

member’s medical condition regarding

the terminal illness and related

conditions.

For hospice members residing in a

nursing facility, the IHCP requires the

hospice provider to meet the

documentation requirements under

Code of Federal Regulations 42 CFR

418.112 to reflect a coordinated plan

of care between hospice and nursing

facility agencies that demonstrates the

hospice care philosophy supersedes in

the care of the nursing facility

resident.

Yes No

Form Description

Required for

Medicaid-Only

Member?

Required for

Dually Eligible

Member?

Medicaid Hospice

Plan of Care for

Curative Care –

Members 20 Years

and Younger (State

Form 54896)

This form is for reporting on the

terminal illness and related conditions

of members 20 years of age and

younger, when concurrent hospice

services and curative treatment are

elected. The hospice interdisciplinary

team and the curative care team

complete this form together,

describing both the hospice and

curative services to be rendered. The

hospice provider must include all

hospice services and supplies within

the hospice per diem that are necessary

to treat the member's terminal illness

and related conditions.

Yes, for

members age 20

and younger who

elect concurrent

hospice and

curative care

benefits

No

Hospice Provider

Change Request

Between Indiana

Hospice Providers

(State Form 48733

[R/12-02]/OMPP

0009)

A member (or representative of the

member) who is not satisfied with a

hospice provider can use this form to

change hospice providers during any

benefit period. The hospice provider

can submit this form to the IHCP FFS

PA-UM contractor as long as all

hospice benefit periods preceding the

date of the hospice revocation were

previously authorized.

Yes Yes

Change in Status of

Medicaid Hospice

Patient

(State Form 48732

[4-98]/OMPP 0010)

This form is used when an IHCP

member already enrolled in the IHCP

hospice benefit becomes eligible for

Medicare benefits midway through

IHCP hospice care. The hospice

member must be enrolled in the

Medicare hospice benefit at the same

time of Medicare eligibility. In this

situation, this form must be completed

and sent to the IHCP Hospice

Authorization Unit. This form

indicates that the IHCP member is

now eligible for Medicare. For such

individuals, before the initiation of

hospice care, hospice providers must

make adequate preparation in the

event the IHCP hospice member

becomes Medicare-eligible.

No, not if they

remain ineligible

for Medicare

Yes, if they

became dually

eligible during a

Medicaid-only

benefit period

Medicaid Hospice

Revocation

(State Form 48735

[4-98]/OMPP 0007)

This form is used when a member

revokes or chooses not to continue

having hospice services.

Yes Yes

Form Description

Required for

Medicaid-Only

Member?

Required for

Dually Eligible

Member?

Medicaid Hospice

Discharge

(State Form 48734

[R/12-02]/OMPP

0008)

Hospice providers complete this form

when they wish to discharge a

member, for example, because the

member is moving out of the hospice’s

service area or transferring to another

hospice, because the provider

determines that the member is no

longer terminally ill, or “for cause,” as

described in 42 CFR 418.26(a)(3).

Yes Yes

Hospice providers must provide the same services to a hospice member residing in a nursing facility or

intermediate care facility for individuals with intellectual disabilities (ICF/IID) as it would have provided if

the hospice member had been residing in their private home, as governed by federal regulations at 42 CFR

418.112 Condition of Participation: Hospices That Provide Hospice Care to Residents of a SNF/NF or

ICF/IID. This section states the plan of care must describe, to the extent possible, the par ticipation of the

hospice, the facility and the patient. The hospice and the facility must communicate with each other when any

changes are included in the plan of care, and each provider must be aware of the other’s responsibilities for

implementing the plan of care. Evidence of this coordinated plan of care must be present in the clinical

records of both providers. All aspects of the plan of care must reflect the hospice care philosophy.

Failure to meet this medical documentation and charting criteria for a hospice patient at the nursing facility or

ICF/IID is a violation of the Medicare hospice conditions of participation and Indiana state hospice licensure.

Because the IHCP is the payer of last resort, the IHCP hospice benefit has unique reimbursement issues and

patient coordination issues different from the Medicare program. For this reason, the IHCP recommends

hospice providers include the previously mentioned forms in a hospice member’s facility chart. The

inclusion of the listed forms permits the facility staff to understand a particular member is enrolled in the

IHCP hospice benefit or an individual’s hospice status has changed due to hospice election, re vocation or

discharge. This goal cannot be accomplished if only a coordinated plan of care is included in the hospice

member’s facility medical record chart.