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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.9 Private Duty Nursing (CCP) : 2.9.3 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.
An advanced practice registered nurse (APRN) or a physician assistant may sign all documentation related to the provision therapy services on behalf of the client’s physician when the physician delegates this authority to the APRN or physician assistant.
Requests for nursing services must be submitted on the required Medicaid authorization forms and include supporting documentation. The supporting documentation must:
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:
If birth through 17 years of age, the client resides with a 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, OT, PT, ST, primary home care (PHC), and case management services.
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.
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 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.
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 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 responsible adult and is indicated on the submitted POC as the SOC date.
Prior authorizations for more than 16 hours per day are not issued to a single, independently-enrolled nurse. Requests for prior authorizations of PDN must always be commensurate with the client’s medical needs. Requests for services must 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 six months at a time.
PDN is not prior authorized under any of the following conditions:
The client’s needs are within the scope of services available through Texas Medicaid (Title XIX) Home Health Services SN 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 skilled nursing services may be prior authorized only for the client/caregiver who will be trained in TPN administration.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.