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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 : 2.9.3.9 CCP Prior Authorization Request Form

2.9.3.9
The CCP Prior Authorization Request Form must be completed, signed, and dated by the physician. The physician must mark the Private Duty Nursing box documenting the stability of the client for PDN. All requested dates of service must be included.

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