Ind. IHCP Hospice Services Provider Reference Module, Section 7, Recognition of Hospice Review Process at 405 IAC 5-34-4.2

405 IAC 5-34-4.2 recognizes the hospice review process and specifies the audit of hospice services shall

include review of the medical record to determine the medical necessity of services based on applicable

current professional standards. The IHCP retains the right to review medical necessity and will continue to

do so through the IHCP fee-for-service (FFS) hospice authorization process, IHCP Program Integrity audit

process, and follow-up on any reported cases of program misutilization from other state agencies.

The IHCP recognizes the Local Coverage Determination (LCD) is only a guide to assist providers in

determining if a patient is appropriate for hospice care and is not meant to replace the overall clinical

evaluation either by the hospice provider or by the IHCP and its contractor in evaluating the unique clinical

condition of each hospice member. Each hospice authorization is reviewed as a stand-alone request and

should take into consideration the hospice member’s unique clinical history.

Hospice providers must adhere to the LCD published by the Part A Medicare Administrative Contractor

(MAC) for the state of Indiana when evaluating a Medicaid-only hospice member for hospice care

appropriateness.