TMPPM 2008 > Texas Medicaid Services > Texas Health Steps (THSteps) > THSteps-Comprehensive Care Program (CCP)

43.4.13.5 Prior Authorization

Prior Authorization Requirements

When a provider receives a referral for PDN, the provider must have an RN perform a nursing assessment of the client within the client's home environment. This assessment must be performed before seeking prior authorization for PDN, with any request for PDN recertification, or any request to modify PDN hours. The assessment must demonstrate the following:

•Medical necessity for PDN.

•Safety of providing care in the proposed setting.

•If birth through 17 years of age, the client resides with an identified responsible adult who is either trained to provide nursing care or is capable of initiating an identified contingency plan when the scheduled private duty nurse or qualified aide is unexpectedly unavailable.

•An identified responsible adult is an individual 18 years of age or older who has agreed to accept the responsibility for a client's provision of food, shelter, clothing, education, nurturing, and supervision. Responsible adults include: biological parents, adoptive parents, foster parents, guardians, individuals court-appointed as managing conservators, and other family members by birth or marriage.

•An identified contingency plan is a structured process, designed by the responsible adult and the PDN provider, by which a client will receive care when a scheduled private duty nurse or qualified aide is unexpectedly unavailable, and the responsible adult is unavailable, or is not trained, to provide the nursing care. The identified responsible adult must be able to initiate the contingency plan.

•The existing level of care and any additional health-care services including the following: SHARS, MDCP, PT, OT, ST, primary home care (PHC), and case management services.

Note: Services provided under these programs do not prevent a client from obtaining all medically necessary services. Certain school services are provided to meet education needs, not medical needs. Records related to a client's Individuals with Disabilities Education Act (IDEA) services are confidential records that clients do not have to release or provide access to.

When an RN completes a client assessment and identifies a medical necessity for ADLs or health-related functions to be provided by a nurse or by a qualified aide under the supervision of an RN, the scope of PDN services may include these ADLs or health-related functions.

Note: THSteps-CCP does not review or authorize PDN based on partial or incomplete documentation.

PDN must be prior authorized, and requests for PDN must be based on the current medical needs of the client.

The following criteria are considered for PDN prior authorization:

•The documentation submitted with the request is complete.

•The requested services are nursing services as defined by the Texas Nursing Practice Act and its implementing regulations.

•The explanation of the client's medical needs is sufficient to support a determination that the requested services correct or ameliorate the client's disability, physical or mental illness, or chronic condition.

•The client's nursing needs cannot be met on an intermittent or part-time basis through Texas Medicaid (Title XIX) Home Health Services skilled nursing services.

•There is no TPR financially responsible for the services.

Only those services that THSteps-CCP determines to meet the medical necessity criteria for PDN are reimbursed. Before THSteps-CCP determines the requested nursing services do not meet the criteria, the TMHP medical director contacts the treating physician to determine whether additional information or clarification can be provided that would allow for the prior authorization of the requested PDN. If the TMHP medical director is not successful in contacting the treating physician or cannot obtain additional information or clarification, the TMHP medical director makes a decision based on the available information.

Providers must obtain prior authorization within three calendar days of the SOC for services that have not been prior authorized. During the prior authorization process, providers are required to deliver the requested services from the SOC date. The SOC date is the date agreed to by the physician, the PDN provider, and the client or parent/guardian and is indicated on the submitted POC as the SOC date.

Note: THSteps-CCP does not prior authorize an SOC date earlier than seven calendar days before contact with TMHP.

Prior authorization is a condition for reimbursement, not a guarantee of payment.

Prior authorizations for more than 16 hours per day are not issued to a single, independently enrolled nurse.

Requests for prior authorizations of PDN should always be commensurate with the client's medical needs. Requests for services should reflect changes in the client's condition that affect the amount and duration of PDN.

The length of the prior authorization is determined on an individual basis and is based on the goals and timelines identified by the physician, provider, and client or parent/guardian. PDN is not prior authorized for more than six months at a time.

PDN is not prior authorized under any of the following conditions:

•The client does not meet medical necessity criteria.

•The client does not have a primary physician.

•The client is 21 years of age or older.

•The client's needs are within the scope of services available through Texas Medicaid (Title XIX) Home Health Services SN and/or home health agency services because the needs can be met on a part-time or intermittent basis.

Start of Care (SOC)

The SOC is the date that care is to begin, as agreed on by the family, the client's physician, and the provider, and as listed on the POC and the THSteps-CCP Prior Authorization Request Form. Providers are responsible for determining whether they can accept the client for services.

Once the provider accepts a client for service and accepts responsibility for providing PDN, the provider is required to deliver those services beginning with the SOC date. Providers are responsible for a safe transition of services when the authorization decision is a denial or a reduction of services. Providers are required to notify the physician and the client's family on receipt of an authorization, a denial, or a change in PDN.

Providers must submit complete documentation no later than three business days from an SOC date to obtain initial coverage for the SOC date.

Note: Texas Medicaid (Title XIX) Home Health Services does not authorize a SOC date earlier than three business days before contact with TMHP.

For PDN extensions, THSteps-CCP must receive complete documentation no later than 3 business days before the SOC date. It is recommended that extension requests be submitted up to 30 days before the current authorization ends.

During the prior authorization process for initial and extension requests, providers are required to deliver the requested services from the SOC date.

Prior Authorization of Initial Requests

Completed initial requests must be received and dated by THSteps-CCP within three business days of the SOC. The request must be received by THSteps-CCP no later than 5 p.m., Central Time, on the third day to be considered received within three business days. If a request is received more than three business days after the SOC, or after 5 p.m., Central Time, on the third day, authorization is given for dates of service beginning three business days before receipt of the completed request.

Example: A provider begins PDN services on Monday, June 1. The completed request is received by THSteps-CCP on Friday, June 5. The authorization will start on Tuesday, June 2 (three business days before June 5). If the complete request had been received on Thursday, June 4, the authorization would have started on June 1, as requested.

Initial requests for PDN generally are considered for up to 60 days of services.

Authorization for Revision of Current Services

Completed requests for revision of PDN hours during the current authorization period must be received by THSteps-CCP within three business days of the revised SOC. The request must be received by THSteps-CCP no later than 5 p.m., Central Time, on the third day to be considered received within three business days. If a request is received more than three business days after the revised SOC or after 5 p.m., Central Time, on the third day, authorization is given for dates of service beginning three business days before receipt of the completed request.

Revisions to a current certification must fall within the certification period. If the revision extends beyond the current certification period, new authorization documentation must be submitted to THSteps-CCP.

Example: A provider begins PDN services on Monday, June 1. The client becomes ill on Friday, June 5, and requires increased skilled nursing intervention of a short duration. The completed revision request is received by THSteps-CCP on Thursday, June 11. The authorization will start on Monday, June 8 (three business days before June 11). If the complete request had been received on Wednesday, June 10, the revision authorization would have started on June 5, as requested.

Revision requests for PDN generally are considered for up to 60 days of services.

Recertifications of Authorizations

Completed extension requests must be received and dated by THSteps-CCP at least 7 calendar days before, but no more than 30 days before, the current authorization expiration date. The request must be received by THSteps-CCP no later than 5 p.m., Central Time, on the seventh day, to be considered received within 7 calendar days. If a request is received less than 7 calendar days before the current authorization expiration date, or after 5 p.m., Central Time, on the seventh day, authorization is given for dates of service beginning no sooner than 7 calendar days after the receipt of the completed request by THSteps-CCP.

Example: A provider has a current prior authorization that expires on June 10. The completed request is received by THSteps-CCP on June 2, eight calendar days before the current authorization period ends. The authorization for extension will begin on June 11, as requested. If the completed request had been received on June 15, the prior authorization could not begin until June 12, instead of June 11, as requested.

Recertification requests for PDN are considered for up to 60 days of services.

Extended Authorizations

THSteps-CCP accepts requests for extended authorizations for PDN. Extensions may be authorized for four or six months. The following criteria are required for extended authorization:

•The client has received PDN services for at least a year.

•The client's condition has been medically stable for at least six months.

•PDN requests and authorizations for the previous six months have been at the same level.

•No significant changes in the client's condition are anticipated.

•The client's parent/guardian, physician, and provider agree that an extended authorization is appropriate.

The extended authorization process involves the following:

•All required documentation for PDN services (including the Physician POC, the Nursing Care Addendum to POC, and the THSteps-CCP Prior Authorization Request Form) is submitted.

•Dates of service on the THSteps-CCP Prior Authorization Request Form covers four or six months as appropriate.

•A THSteps-CCP Prior Authorization Private Duty Nursing 4 or 6 Month Authorization is attached. This form must include all required information and signatures.

•The nursing care provider is responsible for ensuring that a new Physician POC is obtained every 60 days and maintained in the client's record. Providers should not submit interim POCs to THSteps-CCP unless requesting a revision.

•The nursing care provider should notify THSteps-CCP at any time during the authorization period if the client's condition and need for skilled nursing care significantly changes.

•The nursing care provider may request a revision from TMHP at any time during the authorization period if the client's condition requires it.

•All authorization timelines apply to extended authorizations also.

Refer to: "Nursing Addendum to Plan of Care (THSteps-CCP) (7 Pages)"

"THSteps-CCP Prior Authorization Private Duty Nursing 4 or 6 Month Authorization".

Termination of Authorization

An authorization may be terminated when the:

•Client is no longer eligible for THSteps-CCP or Medicaid.

•Client no longer meets the medical necessity criteria for PDN.

•POS can no longer accommodate the client's health and safety.

•Client or parent/guardian refuses to comply with the service plan and compliance is necessary to assure the client's health and safety.

Client/Provider Notification

When PDN is approved as requested, the provider receives written notification. The provider is responsible for notifying the client/family and the physician of the authorized services.

THSteps-CCP notifies the client and provider in writing when the following instances occur:

•PDN is denied.

•PDN hours authorized are less than the hours requested on the POC.

•PDN hours are modified (e.g., hours are requested by the week but are authorized by the day).

•THSteps-CCP receives incomplete information from the provider.

•Dates of service authorized are different from those requested.

•The provider is responsible for notification and coordination with the physician and family.

Authorization Appeals

Providers may appeal denials or modifications of requested PDN with documentation to support the medical necessity of the requested PDN. A request for authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply. Appeals must be submitted to THSteps-CCP with complete documentation and any additional information within two weeks of the date on the decision letter. If changes are made to the authorization based on this documentation, THSteps-CCP goes back no more than three business days for initial or revision requests and no more than seven calendar days for extension requests when additional documentation is submitted.

The client or parent/guardian are notified of any denial or modification of requested services and are given information about how to appeal THSteps-CCP's decision.