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3.9.3 Prior Authorization and Documentation Requirements
A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply.
Requests for nursing services must be submitted on the required Medicaid authorization forms and include supporting documentation. The supporting documentation must:
• Clearly and consistently describe the client's current diagnosis, functional status, and condition.
•Consistently describe the treatment throughout the documentation.
•Provide a sufficient explanation as to how the requested nursing services correct or ameliorate the client's disability, physical or mental illness, or condition.
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 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 is unexpectedly unavailable.
•"Responsible adult" means an individual who is an adult, as defined by the Texas Family Code, and who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for the recipient. Responsible adults include, but are not limited to: biological parents, adoptive parents, foster parents, guardians, court-appointed 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 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, the scope of PDN services may include these ADLs or health-related functions.
Note: 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 CCP determines to meet the medical necessity criteria for PDN are reimbursed. Before 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 3 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 responsible adult and is indicated on the submitted POC as the SOC date.
Note: CCP does not prior authorize an SOC date earlier than 7 calendar days before contact with TMHP.
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 responsible adult. PDN is not prior authorized for more than 6 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.
Intermittent skilled nursing visits for clients who receive private duty nursing (PDN) and who require TPN administration education may be considered for separate prior authorization if:
•The PDN provider is not an RN who has been appropriately trained in the administration of TPN, and the PDN provider is not able to perform the function.
•There is documentation that supports the medical need for an additional skilled nurse to perform TPN .
The skilled nursing services may be prior authorized only for the client/caregiver who will be trained in TPN administration.
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