Indiana Health Coverage Programs - Hospice Provider Services

Hospice Forms

The IHCP requires hospice providers to use the IHCP hospice forms for IHCP-only hospice members. The IHCP hospice forms contain the necessary information to enroll an individual in the IHCP hospice program and provide the standardization to facilitate workflow for the Medicaid prior authorization contractor.

Forms may be obtained through the Indiana Commission on Public Records - Forms Management Division - Family and Social Service Administration (FSSA) Forms Catalog website.

To obtain forms when web access is not available, submit a written request specifying the form name, number, and quantity (in multiples of 50) on the hospice provider’s letterhead to:

Forms Distribution Center
6400 E. 30th Street
Indianapolis, Indiana 46219

Completed forms should be mailed to:

ADVANTAGE Health Solutions, Inc.^SM
Prior Authorization Department
P.O. Box 40789
Indianapolis, IN 46240

To determine the specific form needed, please read the following form descriptions.

Hospice Accounts Receivable Refund Adjustment
Accounts Receivable Refund Adjustment
	This form is used when Medicaid Hospice claims are billed with revenue codes 653 and/or 654. 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. Also, if other insurance and the IHCP reimbursed the provider for hospice care services, the provider was overpaid and must refund the overpayment to the IHCP.

Medicaid Hospice Plan of Care
State Form 48731 / OMPP 0011
	This form is for reporting a hospice member's terminal illness and related conditions. The hospice interdisciplinary team completes this form to specify the plan of care. The Balanced Budget Act of 1997 specifies that hospices must include all services and supplies within the hospice per diem that are necessary to treat the hospice member's terminal illness and related conditions. The Medicaid Hospice Plan of Care form has been revised in November 2004 to reflect three signatures. Effective March 6, 2009, the instructions on the Medicaid hospice plan of care have been revised to reflect that the hospice must have two additional signatures from the disciplines on the form and the signature of the hospice medical director. The IHCP has requested that the Forms Distribution Center deplete the prior version of the form, which has two signature lines. The IHCP has specified to hospice providers to continue to enter the third signature when the prior version of the form is used. The new version of Medicaid Hospice Plan of Care form is now available and can be downloaded from the state website as well as this IHCP website. If the required three signatures are not present, Advantage Health Solutions Prior Authorization Unit is required to return the form for the third signature and modify the start dates of the hospice authorization. This is consistent with the timeliness requirement that all forms have the required signatures within 10 business days from the start of a hospice benefit period. The IHCP has further information on this revision within the March 2005 Newsletter.

Change in Status of Medicaid Hospice Patient
State Form 48732 / OMPP 0010
	The hospice must complete and submit this form whenever the hospice member has moved from the private home to an institutional setting, from an institutional setting to the private home, or from a prior institutional setting to a new institutional setting.

Hospice Provider Change Request Between Indiana Hospice Providers
State Form 43733 / OMPP 0009
	This form is used when a hospice member elects to change the hospice provider once during a hospice benefit period. This form must first be submitted by the current/original provider along with the Medicaid Hospice Discharge Form. Upon receipt of the Discharge and Change forms from the current provider, the HCE hospice analyst will update the system to reflect the date of hospice discharge. At this time, the new provider can submit this form to indicate he is the new hospice provider. Processing the paperwork from the original/current provider first will ensure that HCE can authorize the paperwork of the new hospice provider and with minimal interruption.

Medicaid Hospice Discharge
State Form 48734 / OMPP 0008
	The hospice must complete this form when the patient is discharged from the hospice program due to death, prognosis greater than six months or less, safety of recipient or hospice staff is compromised, or recipient moved out of the hospice provider's service area. Hospice discharge is a provider-initiated action.

Medicaid Hospice Revocation
State Form 48735 / OMPP 0007
	A member may opt to revoke his hospice benefit when the member or the member's representative signs the hospice form. Federal regulations require hospice revocation to be in writing. The effective date of the hospice revocation must be equal to or greater (future) than the date the document is signed. In other words, federal regulations and medical record standards prohibit backdating of hospice revocations. Hospice revocation is a patient initiated action.

Medicaid Hospice Physician Certification
State Form 48736 / OMPP 0006
	The attending physician and the hospice medical director must certify the first hospice benefit period, the medical reason the individual is eligible for hospice, and that the prognosis for life expectancy is 6 months or less if the illness were to run its course. The hospice medical director alone can complete and sign the physician certification form for all subsequent hospice benefit periods.

Medicaid Hospice Election
State Form 48737 / OMPP 0005
	The member or the member's representative must sign this form to elect the hospice benefit and to acknowledge the benefits provided under the hospice benefit. A witness signature is not required under Medicare hospice regulations, so the IHCP will permit a hospice provider to submit this form without including a witness signature for IHCP hospice authorization. This form has been revised in November 2004 to not reflect the witness signature. The IHCP has requested that the State Forms Distribution Center deplete the prior version of the form, which has the witness signature, before requesting a reprint order of the revised form. Providers may download a copy of the revised Medicaid Hospice Election form at the state website as well as this IHCP website. The IHCP has further information on this revision within the March 2005 Newsletter. A date in the future for the start of the hospice care may be designated by the member or the member's representative; however, hospice election cannot be designated a day prior to the date the hospice election is signed. In other words, hospice revocation should never be backdated according to federal regulations and medical records standards.

Hospice Authorization Notice for Dually-Eligible Medicare/Medicaid Nursing Facility Residents
State Form 51098 / OMPP 0014
	The patient care coordinator must complete this form so that the member can be authorized for the IHCP hospice benefit