Section 405 IAC 5-34-4 - Hospice authorization and benefit periodsAuthority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-40
Affected: IC 12-15
Sec. 4.
(a) Hospice services require Medicaid hospice authorization by the office or its contractor. Medicaid reimbursement is not available for hospice services furnished without authorization.(b) To request hospice authorization for Medicaid-only eligible members for each hospice benefit period, the provider must submit all of the following documentation on forms approved by the office: (1) Member election statement.(2) Medicaid physician certification.(3) Medicaid plan of care.(c) Dually-eligible Medicare/Medicaid members residing in nursing facilities who elect hospice benefits must enroll simultaneously in the Medicare and Medicaid hospice benefits. To obtain hospice authorization, the hospice provider must submit the following forms as approved by the office for a one (1) time enrollment in the Medicaid hospice benefit: (1) Medicaid Hospice Authorization Notice for Dually-Eligible Medicare/Medicaid Nursing Facility Residents.(2) A copy of the hospice agency form reflecting the member's election of the Medicare hospice benefit. The form must reflect the signature of the member or the member's representative and the date on which the form was signed. The hospice provider is required to resubmit the forms described in this subsection when a dually-eligible Medicare/Medicaid hospice member residing in a nursing facility reelects the Medicare and the Medicaid hospice benefit following a previous hospice revocation or hospice discharge.
(d) Hospice authorization is not required for the dually-eligible Medicare/Medicaid hospice member residing at home as Medicare is reimbursing for the hospice care.(e) Hospice authorization for the Medicaid-only hospice member is available in the following consecutive benefit periods:(1) One (1) period of ninety (90) days.(2) A second period of ninety (90) days.(3) An unlimited number of periods of sixty (60) days.(f) Hospice authorization must be granted separately for each benefit period for the Medicaid-only hospice member. If benefit periods beyond the first ninety (90) days are necessary, then recertification on the physician certification form and an updated plan of care are required for authorization of the second and subsequent benefit periods. For the dually-eligible Medicare/Medicaid hospice member residing in a nursing facility, hospice authorization is granted one (1) time at the time of enrollment in the Medicaid hospice benefit. Hospice authorization is not required for each hospice benefit period. Hospice authorization is required when the dually-eligible Medicare/Medicaid hospice member residing in a nursing facility reelects the Medicare and the Medicaid hospice benefit following a previous hospice revocation or hospice discharge.(g) In order to obtain authorization and reimbursement for hospice services, the provider must submit the documentation listed in this section to the office or its contractor within ten (10) business days of the effective date of the member's election, and within ten (10) business days of the beginning of the second and subsequent benefit periods if required under this section.(h) When there is insufficient information submitted to render a hospice authorization decision or the documentation contains errors, a hospice authorization request will be suspended for thirty (30) days and the office or its contractor will request additional information from the provider. The provider must make the corrections and resubmit the proper documentation to the office or its contractor within thirty (30) calendar days after the additional information or correction is requested. If the provider fails to resubmit the documentation with the appropriate corrections within the thirty (30) day time period, the request for hospice authorization will be denied. If the provider submits additional documentation within thirty (30) days, but the documentation submitted does not provide sufficient information to render a decision, the office or its contractor may request additional information. The provider must submit the additional information within thirty (30) days after the additional information is requested. If the provider fails to submit the requested information within the additional thirty (30) days, or if the additional documentation does not provide sufficient information to render a decision, the request for hospice authorization will be denied.(i) If a request for hospice authorization or supporting documentation are submitted after the time limits in this section, authorization may be granted only for services provided on or after the date that the request is received. Authorization for services furnished prior to the date of a request that does not comply with the time limits in this section may be granted only under the following circumstances: (1) Pending or retroactive member eligibility. The hospice authorization request must be submitted within twelve (12) months of the date of the issuance of the member's Medicaid card.(2) The provider was unaware that the member was eligible for services at the time services were rendered. Hospice authorization will be granted in this situation only if the following conditions are met:(A) The provider's records document that the member refused or was physically unable to provide the member identification (RID or Medicaid) number.(B) The provider can substantiate that the provider continually pursued reimbursement from the patient until Medicaid eligibility was discovered.(C) The provider submitted the request for prior authorization within sixty (60) days of the date Medicaid eligibility was discovered.(3) Pending or retroactive approval of nursing facility level of care. The hospice authorization request must be submitted within one (1) year of the date nursing facility level of care is approved by the office.(j) The office will rely on current professional guidelines, including the local Medicare medical review policies for hospice services, in making the hospice authorization determination.(k) When approval for a benefit period has been granted, a hospice provider may manage a patient's care at the four (4) levels of care according to the medical needs determined by the interdisciplinary team and the requirements of the patient and the patient's family or primary caregivers. Changes in levels of care do not require prior authorization as long as these levels are rendered within a prior approved hospice benefit period.Office of the Secretary of Family and Social Services; 405 IAC 5-34-4; filed Mar 9, 1998, 9:30 a.m.: 21 IR 2380; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Jun 5, 2003, 8:30 a.m.: 26 IR 3636; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR- 405130241RFAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAReadopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA