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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 : Authorization for Revision of Current Services
The provider may request a revision at any time during the authorization period if medically necessary. The provider must notify TMHP at any time during an authorization period if the client's condition changes and the authorized services are not commensurate with the client's medical needs.
Completed requests for revision of PDN hours during the current authorization period must be received by CCP within three business days of the revised SOC. The request must be received by CCP no later than 5 p.m., Central Time, on the seventh day to be considered received within three business days. If a request is received more than three business days after the revised SOC or after 5 p.m., Central Time, on the third day, authorization is given for dates of service beginning three business days before receipt of the completed request.
The revised PDN prior authorization request must include all of the following:
The provider is responsible for ensuring that the physician reviews and signs the POC within 30 calendar days of the start date of the revised authorization period or more often if required by the client's condition or agency licensure. The provider must maintain the physician-signed POC in the client's medical record. PDN providers should not submit a revised POC unless they are requesting a revision.
Revision requests for PDN may be prior authorized up to six months.
If all necessary documentation is not submitted for a six-month authorization, an authorization for a period up to three months may be approved.
Revisions to a current certification must fall within the certification period. If the revision extends beyond the current certification period, new authorization documentation must be submitted to CCP.
Refer to:
Form CH.3, “CCP Prior Authorization Private Duty Nursing 6-Month Authorization” in this handbook.
Form CH.7, “Home Health Plan of Care (POC)” in this handbook.

Texas Medicaid & Healthcare Partnership
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