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April 2015 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 : 2.12.3.8 Authorization Appeals

2.12.3.8
Providers may appeal denials or modifications of requested PDN with documentation to support the medical necessity of the requested PDN. A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply. Appeals must be submitted to 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, CCP goes back no more than three business days for initial or revision requests and no more than seven calendar days for recertification requests when additional documentation is submitted.
The client or responsible adult is notified of any denial or modification of requested services and is given information about how to appeal CCP’s decision.
Documentation forms have been designed to improve communication between providers and CCP. The forms are available in English and Spanish.
All documentation must be submitted together, and requests are not reviewed until all documentation is received. If complete documentation is received at CCP by 3 p.m., Central Time, a response is returned to the provider within one business day. Complete documentation for initial, revision, recertification, and extension requests for PDN authorizations include all of the following:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2013 American Medical Association. All rights reserved.