Policy Updates Prior AuthorizationHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingAugust 23, 2024

Hospice notification updates

Effective October 25, 2024, our Medicaid plans will align with Indiana Health Coverage Program (IHCP) fee-for-service (FFS) for hospice services for the following programs: Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging. This includes the following covered services: home hospice, hospice in a nursing facility (includes room and board), hospice in a hospice facility, and respite hospice care. The following changes will be applied to all hospice services. All hospice care providers must send notification of services.

For dually eligible (Medicare and Medicaid) hospice members, hospice care providers should refer to eligibility requirements in Code of Federal Regulations 42 CFR 418.20, which states:

In order to be eligible to elect hospice care under Medicare, an individual must be: (a) Entitled to Part A of Medicare; and (b) Certified as being terminally ill in accordance with 418.22.

Medicaid-only (non-dual) hospice members must be eligible for the Medicaid program and be certified as terminally ill in accordance with 42 CFR 418.22. Furthermore, the medical documentation contained in the form Medicaid Hospice Physician Certification (state form 48736 [R/12-02]/OMPP 0006) and the form Medicaid Hospice Plan of Care (state form 48731 [R2/11-04]/OMPP 0011) must support a terminal diagnosis versus a chronic condition.

Continuity of care (COC) notifications

Fax the required documentation to 844-765-5157. The notification must contain:

  • IHCP prior authorization (PA) form, including:
    • CPT®/HCPCS code applicable to the hospice service (see below for codes).
    • Do not list revenue codes on the PA form.
    • In the note section of the IHCP PA form, enter COC.
  • The approval letter from FFS or previous MCE containing the allowed units and dates of service:
    • COC dates of service will begin the date the member became eligible and approved for 90 days.
    • If the previously approved service ends prior to the 90th day, the end date of service will follow the approved end date.
  • If services need to continue after the COC period:
    • Submit the notification 14 days before the COC period expires.
    • Include the documentation as outlined below.

Notification of dual members

Service: hospice in a nursing facility or in a hospice facility

Submit the following documentation by fax to 844-765-5157:

  • IHCP PA form, including:
    • The nursing facility or hospice facility National Payer Identifier (NPI) and tax ID (enter in the note section of the PA form).
    • Enter a CPT/HCPCS code (one of the following codes must be listed: Q5003, Q5004, Q5006, Q5007, or T2046).
    • Do not include revenue codes on the IHCP PA form.
    • Your billing will not be impacted by listing the CPT/HCPCS codes on the IHCP PA form since care providers bill with revenue codes.
  • Hospice election form
  • MD signed certification for terminal illness with less than six months of life expectancy
  • Hospice authorization for dually eligible nursing facility residents’ form

Notification for non-dual members

Service: hospice in a nursing facility or in a hospice facility

Submit the following documentation by fax to 844-765-5157:

  • IHCP PA form, including:
    • The nursing facility or hospice facility NPI and tax ID (enter in the note section of the PA form)
    • Enter a CPT/HCPCS code (one of the following codes must be listed: Q5003, Q5004, Q5006, Q5007, or T2046).
    • Do not include revenue codes on the IHCP PA form.
    • Your billing will not be impacted by listing the CPT/HCPCS codes on the IHCP PA form since care providers bill with revenue codes.
  • Hospice election form
  • MD signed certification for terminal illness with less than six months of life expectancy

Notification for all members

Service: home hospice and continuous home hospice

Submit the following documentation by fax to 844-765-5157:

  • IHCP PA form, including:
    • Enter a CPT/HCPCS code (one of the following codes must be listed: Q5001, T2042, or T2043)
    • Do not include revenue codes on the IHCP PA form.
    • Your billing will not be impacted by listing the CPT/HCPCS codes on the IHCP PA form since care providers bill with revenue codes.
  • Hospice election form
  • MD signed certification for terminal illness with less than six months of life expectancy

Notification for all members

Service: respite hospice

Submit the following documentation by fax to 844-765-5157:

  • IHCP PA form, including:
    • Enter a CPT/HCPCS code (one of the following codes must be listed: H0045, T1005, or T2044).
    • If the respite service is for a nursing facility, hospice facility or a hospital, list the NPI and tax ID (enter in the note section of the PA form).
    • Do not include revenue codes on the IHCP PA form.
    • Your billing will not be impacted by listing the CPT/HCPCS codes on the IHCP PA form since care providers bill with revenue codes.
  • Hospice election form..
  • MD signed certification for terminal illness with less than six months of life expectancy

Note: Inpatient respite hospice is allowable only for members who are otherwise residing in a private home and are admitted to the indicated facility for a respite stay only.

Notification for all members

Service: general inpatient hospice related to the terminal illness

Submit the following documentation by fax to 844-765-5157:

  • IHCP PA form, including:
    • Enter a CPT/HCPCS code (one of the following codes must be listed: Q5005 or T2045).
    • If the respite service is for a nursing facility, hospice facility or a hospital, list the NPI and tax ID (enter in the note section of the PA form).
    • Do not include revenue codes on the IHCP PA form.
    • Your billing will not be impacted by listing the CPT/HCPCS codes on the IHCP PA form since care providers bill with revenue codes.
  • Hospice election form.
  • MD signed certification for terminal illness with less than six months of life expectancy.

If the hospice provider has an arrangement with a facility to provide short-term inpatient care, the arrangement must be described in a written agreement. The written arrangement must meet the requirements of 42 CFR 418.108(c). Arranged services must be supported by written agreements as described in 42 CFR 418.100(e).

These services are notification only, and no medical necessity review is conducted. With that, if any of the above elements are missing, Anthem will attempt to call the requesting care provider and/or fax the PA form back to the requesting care provider to submit the missing elements.

Benefit periods

Notification of hospice services must be submitted for each of the benefit period 90-90-60 (see table below), then the open-ended services will begin with notification of the fourth benefit period. The face-to-face encounter must be submitted with the (fourth benefit period — open-ended benefit period). The open-ended benefit period will be open for two years. Please submit approximately 14 days before the authorization expires to fax number 844-765-5157.

Period I

90 days

Period II

90 days (expected maximum length of time for illness to run its course)

Period II

Unlimited number of 60-day periods

Open-ended hospice benefit period

405 IAC 5-34-5 requires that a hospice physician or a hospice nurse practitioner must have a face-to-face encounter with a member receiving hospice care to determine continued eligibility for hospice care for the member’s third benefit period and every benefit period thereafter. The face-to-face encounter must occur not more than 30 calendar days before recertification of the third benefit period and of every subsequent benefit period.

For hospice members in Healthy Indiana Plan, Hoosier Care Connect, and PathWays who require inpatient care, hospice care provider responsibilities depend on whether the stay is related to the terminal illness.

For inpatient stays related to the terminal illness, at the general inpatient hospice level of service or the inpatient respite hospice level of service, the hospice care provider is responsible for the following:

  • Obtaining contracts with all IHCP care providers for arranged services:
    • Reimbursing the facility according to the contract between the hospice care provider and the facility where the member receives care (Note: The contract between the hospice provider and the facility covers all costs related to the terminal illness.)
    • Submitting claims directly to the MCE for reimbursement. (Note: The hospice care provider will be paid at the rate appropriate to the level of service provided to the hospice member; general inpatient hospice level of service will be reimbursed at the general inpatient rate; and inpatient respite hospice level of service will be reimbursed at the respite rate.)

For members receiving inpatient care unrelated to the terminal illness, the facility is responsible for: obtaining PA, as required, from the MCE; submitting claims directly to the MCE for reimbursement; all the member’s care and treatment while the member remains at the facility.

For assistance with questions regarding the PA requirement change, please call Provider Services for the plan listed below.

Provider Services

Hoosier Healthwise

866-408-6132

Healthy Indiana Plan

844-533-1995

Hoosier Care Connect

844-284-1798

Indiana PathWays for Aging

833-569-4739

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.

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PUBLICATIONS: September 2024 Provider Newsletter