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March 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 : CCP Prior Authorization Request Form
The CCP Prior Authorization Request Form must be completed, signed, and dated by the physician. When PDN services are ordered, by signing the form the physician attests and certifies the client’s medical condition is sufficiently stable to permit safe delivery of PDN as described in the plan of care. All requested dates of service must be included.

Texas Medicaid & Healthcare Partnership
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