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State Form 48734/OMPP 0008 - The hospice must complete this form when the patient is discharged from the hospice program because: Hospice discharge is a provider-initiated action.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.Sometimes that information may come from a visit or test performed earlier than the claim in question.Elements of a complete medical record may include: Late entries, addendums, or corrections to a medical record are legitimate occurrences in documentation of clinical services.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.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.

The hospice medical director alone can complete and sign the physician certification form for all subsequent hospice benefit periods.

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 Cooperative Managed Care Services (CMCS) hospice reviewer updates the system to reflect the date of hospice discharge.

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.

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