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December 2014 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.12 Private Duty Nursing (PDN)(CCP) : 2.12.3 Prior Authorization and Documentation Requirements : 2.12.3.10 Home Health Plan of Care (POC)

2.12.3.10
The POC must be recommended, signed, and dated by the client’s primary physician. A POC must meet the standards outlined in the 42 CFR §484.18 related to the written POC. The primary physician must review and revise the POC, in consultation with the provider and the responsible adult, for each prior authorization, or more frequently as the physician deems necessary or the client’s situation changes.
Pursuant to 42 CFR §484.18, the POC must include the following elements:
Note:
Coverage periods do not coincide necessarily with calendar weeks or months but, instead, cover a number of services to be scheduled between a start and end date that is assigned during the prior authorization period. A week includes the day of the week on which the prior authorization period begins and continues for seven days. For example, if the prior authorization starts on a Thursday, the prior authorization week runs Thursday through Wednesday. The number of nursing hours authorized for a week must be contained in that prior authorization week. Hours billed in excess of those authorized for the PAN week are subject to recoupment.

Texas Medicaid & Healthcare Partnership
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