Transcript Slide 1

Hospice Program
Presented by
EDS Provider Field Consultants
October 2009
Agenda
• Session Objectives
• Hospice Process
• Bed Hold Days
• Hospice Reimbursement
• Common Denials
• Helpful Tools
• Questions
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Objectives
At the end of this session, providers will be able to
better understand:
• Hospice Election and the Hospice Process
• When to bill for bed hold days
• Hospice reimbursement
• Common denials and how to correct the denials
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Hospice Process
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Hospice Election
• Prognosis is terminal within six months if the illness runs its
normal course
– Physician completes the Medicaid Physician Certification State
Form 48736 (R/12-02)/OMPP 0006 (HF-3)
• Terminally ill patient elects hospice formally
– Concurrent with the certification process, a member must
elect hospice services by completing a Medicaid Hospice
Election State Form 48737 (R/11-04)/OMPP 0005 indicating a
particular hospice provider
– Election to the hospice benefit requires the member to waive
the following:
•
Other forms of healthcare for treatment of the terminal
illness for which hospice care was elected or for treatment
of a condition related to the terminal illness
•
Services provided by another provider equivalent to the
care provided by the elected hospice provider
•
Hospice services other than those provided by the elected
hospice provider or its contractors
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Hospice Election
• Hospice Prior Authorization –
Plan of care for one benefit
period at a time
–Period I: 90 days
–Period II: 90 days (expected
maximum length of illness to
run its course)
–Period III: Unlimited 60-day
period
• Hospice provider completes
the Medicaid Hospice Plan of
Care State Form 48731
(R2/11-04)/OMPP 0011 (HF-4)
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Revocation by Member
• In the event that a member, or representative of a
member, is not satisfied with hospice care and wishes to
revoke hospice services, the following procedures apply:
– The individual must file a Medicaid Hospice Revocation State
Form 48735 (4/98)/OMPP 0007.
– A member can elect to receive hospice care intermittently,
rather than consecutively, over the three benefit periods.
The member can therefore elect and revoke hospice
coverage an unlimited number of times.
– If a member revokes hospice services at any point in the
three benefit periods, time remaining in that benefit period
is forfeited.
– If a member reelects the IHCP hospice benefit, the member
returns as a reenrollment to the next eligible hospice benefit
period.
– The member or the member's representative must revoke
hospice care in writing for the hospice revocation to be
valid.
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Revocation by Member
• The member or the member’s representative must
specify the date that hospice revocation is to be
effective
• The hospice provider can fax the Medicaid Hospice
Revocation State Form 48735 (4/98)/OMPP 0007 to the
ADVANTAGE Health Solutions-FFS at 1-800-689-2759 if
all hospice benefit period(s) preceding the date of the
hospice revocation have been previously authorized
• For those hospice members residing in a nursing facility
(NF), hospice providers must provide a copy of the
Medicaid Hospice Revocation State Form 48735
(4/98)/OMPP 0007 to the appropriate staff in the NF to
ensure that the form is included in the hospice
member's NF clinical record
• The hospice provider must bill the IHCP for payment of
the hospice per diem and for payment of the NF room
and board for the date of the hospice revocation
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Discharge from Hospice
• While the hospice member initiates hospice revocation,
hospice discharge is a process initiated by the hospice
provider
• A hospice may discharge a patient if:
–Patient moves out of the hospice's service area or
transfers to another hospice
–Hospice determines that the patient is no longer
terminally ill
–Behavior of the patient or other persons in the patient’s
home is disruptive, abusive, or uncooperative to the
extent that delivery of care to the patient or the ability
of the hospice to operate effectively is seriously
impaired
–Patient goes to a noncontracted nursing facility or
noncontracted hospital
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Hospice Level of Services
• Authorized hospice provider
manages the level of service
established by the hospice
authorization within each benefit
period
–Routine home
–Continuous home
–Inpatient respite
–General inpatient
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Election, Plan of Care, and Benefit Period
Process
• Plan of care must be submitted to ADVANTAGE Health Solutions
Fee-for-Service Prior Authorization Department with the Indiana
Prior Authorization Request Form, the Hospice Election Form and
the Medicaid Hospice Physician Certification Form
• The following requirements apply to development of the plan
– Interdisciplinary team member who drafts the plan must confer
with at least one other member of the interdisciplinary team
– One of the conferees must be a licensed physician or nurse, and
all team members must review the plan of care
– All the services stipulated within the plan of care must be
reasonable and necessary for palliation or management of the
terminal illness and related conditions
– Plan of care must be signed by the hospice medical director and
include two signatures from any of the other disciplines listed on
the Medicaid Hospice Plan of Care State Form
– Benefits necessary beyond the first 90-day period require
recertification on the Medicaid Hospice Physician Certification
State Form and an updated Medicaid Hospice Plan of Care State
Form
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Election, Plan of Care, and Benefit Period
Process
• For dually eligible Medicare/Medicaid members in nursing
homes, there is a one-time enrollment in hospice for the
authorization for room and board payment
– Hospice enrollment is end-dated when a member revokes, is
discharged from the hospice program, or becomes Medicaid
ineligible
• Required paperwork for hospice election is as follows:
– Indiana Prior Authorization Form
– Hospice Authorization Notice for Dually Eligible
Medicare/Medicaid Nursing Facility Residents – State Form
51098 (3-03)/OMPP 0014
– Medicare Hospice Election Form
Note: The Medicare Hospice election form is requested so that
ADVANTAGE can line up the Medicaid hospice benefit periods
with the Medicare hospice benefit periods. The hospice must
still have the member sign the hospice election form. A
federal law under OBRA 89 indicates they must elect, revoke,
be discharged, and change providers under both programs.
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Location of Care
Private Home and Institutional Settings
• Revenue Code 651 – Routine home care delivered in a
private home
• Revenue Code 652 – Continuous home care delivered in a
private home
• Revenue Code 653 – Routine home care delivered in a
nursing facility
• Revenue Code 654 – Continuous home care delivered in a
nursing facility
• Revenue Code 655 – Inpatient respite care
• Revenue Code 656 – General inpatient hospice care
• Revenue Code 657 – Hospice direct care physician services
• Revenue Code 659 – Medicare/IHCP dually eligible nursing
facility members only
– A member is considered dually eligible if enrolled in hospice
and has both Medicare Part A and Medicaid. Providers cannot
bill with revenue codes 651 through 656 for these members.
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Programs and Aid Categories Ineligible for
IHCP Hospice Program
• 590 Program members
• Children’s special health care services (CSHCS)
• Assistance to residents of county homes (ARCH)
• Qualified Medicare beneficiaries (QMB-Only)
• Specified low-income Medicare beneficiaries (SLMB)
• Limited benefits to pregnant women under Package B
• Individuals eligible for emergency services under
Package E, formerly referred to as alien
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Special Considerations
• To initiate the disenrollment of a member from
managed care program or Care Select, providers
need to fax the Medicaid Hospice Election State
Form 4837(R/11-04)/OMPP 0005 to ADVANTAGE
Health Solutions at (317) 810-4488
• Providers need to call the hospice reviewer to verify
that the fax was received
• Prior Authorization Notice will specify instructions
and the service dates eligible for payment
Note: Refer to Section 6 of the IHCP Hospice Provider
Manual for additional disenrollment instructions
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Bed Hold Days
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Bed Hold Days
• Revenue Code 180 – Nursing Facility Bed Hold
Non-Paid Revenue Code
• Revenue Code 183 – Nursing facility bed hold
for hospice therapeutic leave days
• Revenue Code 185 – Nursing facility bed hold
policy for hospitalization for services unrelated
to the terminal illness of the hospice member
Note: Revenue codes 180, 183, and 185 are only
used when a hospice member resides in a
nursing facility
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Hospice
Reimbursement
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Hospice Reimbursement
• Hospice services may be billed electronically
using Web interChange, or by using the Health
Insurance Portability and Accountability Act
(HIPAA) 837I transaction
• Hospice services may also be billed on a UB-04
claim form
• Utilize only the hospice revenue codes
• Bill Type “822” goes in box 4 of the UB-04
claim form
• Each date of service is entered on its own detail
line
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Common Denials
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Common Denials, Causes, and Resolutions
594 – Type of Bill Not Covered by IHCP
• Cause – Claim was submitted with a bill type
other than 822
• Resolution – Correct bill type to 822 and
resubmit the claim
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Common Denials, Causes, and Resolutions
4021 – Procedure Code Vs Program Indicator
• Cause – Claim was billed with a revenue code
and a procedure code
• Resolution – Remove procedure code and only
bill with revenue code
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Common Denials, Causes, and Resolutions
2024 – Recipient Ineligible for Hospice Level of Care
• Cause – Member does not have hospice authorization
for the service dates billed
• Resolution – Verify Prior Authorization Notice for
approved hospice start and stop date. If there is a
discrepancy with the approved service dates and the
denied service dates, call Advantage Health Solutions
Prior Authorization Department for correction and
clarification of hospice level of care.
• Cause – Member is enrolled in Care Select or Risk
Based Managed Care.
• Resolution – Member must be disenrolled from Care
Select or Risk Based Managed Care
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Common Denials, Causes, and Resolutions
5001 – Exact duplicate
• Cause – Same provider, recipient number, and date of
service was already billed and paid
• Resolution – Verify Remittance Advice for payment
information
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Common Denials, Causes, and Resolutions
2026 – Hospice Recipient Ineligible for Nursing Home
Level of Care
• Cause – Nursing home Level of Care is not on file for
member.
• Resolution – Form 450B must be on file with the
Division of Aging Long Term Care Unit. Level of Care
must be entered into IndianaAIM.
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Helpful Tools
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IHCP Helpful Tools
Primary sources for information about the IHCP are
found at:
• Family and Social Services Administration (FSSA)
Web site at www.in.gov/fssa
• IHCP Web site at www.indianamedicaid.com
• IHCP Provider Manual
• IHCP Hospice Provider Manual
• IHCP provider monthly newsletters
• IHCP provider bulletins
• IHCP provider banner pages
• Indiana Administrative Code at
www.in.gov/legislative/iac/title405.html
Note: The IHCP reference tools apply to fee-forservice/Traditional Medicaid, not the risk-based
managed care delivery system
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Questions
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Office of Medicaid Policy and Planning (OMPP)
402 W. Washington St, Room W374
Indianapolis, IN 46204
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October 2009