october 2009 presented by eds provider field consultants hospice program

October 2009

Presented by

EDS Provider Field Consultants

Hospice Program

Hospice Program2 / October 2009

Agenda

•Session Objectives

•Hospice Process

•Bed Hold Days

•Hospice Reimbursement

•Common Denials

•Helpful Tools

•Questions


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


Hospice Process


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


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)


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.


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


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


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


• 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

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.

Election, Plan of Care, and Benefit Period Process


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.


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


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


Bed Hold Days


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


Hospice Reimbursement


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


Common Denials


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



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



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



5001 – Exact duplicate

•Cause – Same provider, recipient number, and date of service was already billed and paid

•Resolution – Verify Remittance Advice for payment information



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.


Helpful Tools


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-for-service/Traditional Medicaid, not the risk-based managed care delivery system


Questions

October 2009

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october 2009 presented by eds provider field consultants hospice program

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