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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.
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Hospice Accounts Receivable Refund Adjustment |
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Accounts Receivable Refund Adjustment |
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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.
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Medicaid Hospice Plan of Care |
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State Form 48731 / OMPP 0011 |
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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. 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 the
Medicaid Hospice Plan of Care
form is now available and can be downloaded from
the state website as well as this IHCP website. HCE Prior Authorization Unit is required to
return the form for the third signature if hospice providers do not comply. The IHCP has
further information on this revision within the
March 2005 Newsletter.
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Change in Status of Medicaid Hospice Patient |
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State Form 48732 / OMPP 0010 |
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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. |
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Hospice Provider Change Request Between Indiana Hospice Providers |
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State Form 43733 / OMPP 0009 |
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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. |
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Medicaid Hospice Discharge |
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State Form 48734 / OMPP 0008 |
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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. |
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Medicaid Hospice Revocation |
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State Form 48735 / OMPP 0007 |
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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. |
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Medicaid Hospice Physician Certification |
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State Form 48736 / OMPP 0006 |
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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. |
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Medicaid Hospice Election |
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State Form 48737 / OMPP 0005 |
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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.
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Hospice Authorization Notice for Dually-Eligible Medicare/Medicaid Nursing Facility Residents |
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State Form 51098 / OMPP 0014 |
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The patient care coordinator must complete this form so that the member can be authorized for the IHCP hospice
benefit |
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