Forms

The Indiana Health Coverage Programs (IHCP) requires hospice providers to use 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.

Completed hospice authorization forms for medical necessity may be faxed to Cooperative Managed Care Services (CMCS) at 1-800-689-2759.

Paperwork requesting disenrollment of managed care members electing the IHCP hospice benefit must be faxed to (317) 810-4488.

Providers may refer to the IHCP Managed Care Member Electing the IHCP Hospice Benefit in the Hospice Services provider reference module for more information.

To determine which form you need, please see the following descriptions. To access a form, click on the title and locate the form on the Forms page of this website.

Hospice Accounts Receivable Refund Adjustment

Accounts Receivable Refund Adjustment - 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 - 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 hospice must include all services and supplies within the hospice per diem that are necessary to treat the member's terminal illness and related conditions.

The Medicaid hospice plan of care requires the signature of the hospice medical director and two additional signatures of the hospice interdisciplinary team members listed on the form. If the required three signatures are not present, the form will be returned and the start date of hospice authorization will be modified. This practice 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.

Medicaid Hospice Plan of Care for Curative Care Members 20 Years and Younger

State Form 54896 - 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 IHCP expects providers from both teams to interact and coordinate all services. The hospice plan of care is supervised by the hospice provider and the curative plan of care by other IHCP providers. 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.

This form requires the signature of the hospice medical director and two additional signatures from members of the curative care disciplines listed on the form. If the required three signatures are not present, the form is returned, and the start date of hospice authorization modified. This practice 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.

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 a private home to an institutional setting, from an institutional setting to a private home, or from a prior institutional setting to a new institutional setting.

Hospice Provider Change Request Between Indiana Hospice Providers

State Form 48733/OMPP 0009 - Used when a hospice member elects to change his or her hospice provider (allowed once during a hospice benefit period). This form must first be submitted by the current/original provider, along with the Medicaid Hospice Discharge Form, before the change.

Upon receipt of the discharge and change forms from the current provider, the CMCS hospice reviewer updates the system to reflect the date of hospice discharge. At this time, the new provider can submit this form to indicate he or she is the new hospice provider. Processing the paperwork from the original/current provider first ensures that CMCS can authorize the paperwork of the new hospice provider 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, a prognosis greater than six months, the safety of recipient or hospice staff is compromised, or the 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 or her 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 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 six 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 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, federal regulations and medical record standards prohibit backdating hospice revocations.

State Form 55896 - This form is the Spanish-language version of the Hospice Election Form.

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 the member can be authorized for the IHCP hospice benefit.