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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.14 * Prescribed Pediatric Extended Care Centers (PPECC) (CCP) : 2.14.1 Services, Benefits, and Limitations : 2.14.1.1 Prior Authorization and Documentation Requirements

2.14.1.1
Prior authorization is required for PPECC services. All requests for PPECC services must be based on the client’s current medical needs. Texas Medicaid defines medically necessary THSteps services as health care, diagnostic services, treatments, and other measures necessary to correct or ameliorate any disability, physical or mental illness, or chronic conditions.
Documentation of medical necessity is required for PPECC services. PPECC services are considered medically necessary when a client meets all of the following admission criteria:
Requires ongoing skilled nursing care and supervision, skillful observations, judgments and therapeutic interventions all or part of the day to correct or ameliorate health status;
Has a prescription for PPECC services signed and dated by an ordering physician who has personally examined the client within 30 calendar days prior to admission and reviewed all appropriate medical records;
Has consent for the client’s admission to the PPECC signed and dated by the client or the client’s responsible adult. Admission must be voluntary and based on the preference for PPECC services in place of PDN by the client or client’s responsible adult in both managed care and non-managed care service delivery systems.
The PPECC will hold interdisciplinary conferences when PPECC services are initiated, recertified, or revised, and at least every 90 calendar days. Interdisciplinary conferences should include the client’s responsible adult and the following, as applicable:
Note:
For clients who receive their PPECC services through a Medicaid managed care organization, the MCO service coordinator and/or service manager should be included in interdisciplinary conferences.
When the sole purpose of PPECC services is to train and educate the client’s responsible adult or the client (e.g., how to administer total parenteral nutrition (TPN) or how to manage a chronic condition), PPECC services will not be approved.
Training in a home setting for certain services such as how to administer TPN may be considered through intermittent home health skilled nursing visits.
Refer to:
The Home Health Nursing and Private Duty Nursing Services Handbook (Vol. 2, Provider Handbooks) for more details on training and education for the client or the client’s responsible adult on TPN administration in a home setting.
2.14.1.1.1
Initial requests may be prior authorized for a maximum of 90 calendar days. Requests for the prior authorization, including all required documentation, must be submitted to the Texas Medicaid Claims Administrator by electronic portal, fax, or mail no later than three (3) business days following the start of care (SOC). Requests received after the three (3) business day period allowed will be denied for dates of service (DOS) that occurred before the date the request is received.
When PPECC services are authorized, the authorized period begins on the day of the week that prior authorization starts. For example, if services hours are authorized on a weekly basis, the period would begin from the day of the week the prior authorization period begins and continue for seven (7) calendar days. PPECC services may be authorized on a daily, weekly, or hourly basis.
Consistent with PPECC licensure requirements, an initial nursing assessment must be completed, signed and dated by the PPECC Registered Nurse (RN) no earlier than three (3) business days before the SOC at the PPECC. The initial nursing assessment must be performed by a PPECC RN and cannot be delegated. The initial nursing assessment is used to establish the POC and must support medical necessity for the client to receive on-going skilled nursing care. The assessment must include, but is not limited to the following:
Identified medical, nursing, psychosocial, therapeutic, nutritional, dietary, functional, educational, and developmental needs and goals, and any training needs for the client or the client’s responsible adult;
The client’s equipment needs and whether the setting can support the health and safety needs of the client and is adequate to accommodate the use, maintenance, and cleaning of all medical devices, equipment, and supplies required by the client;
Note:
Initial prior authorization requests for PPECC services must include the following documentation:
A completed Prescribed Pediatric Extended Care Center (PPECC) Plan of Care (POC) form signed and dated by the ordering physician, the PPECC RN completing the POC, and client or client’s responsible adult. A PPECC may also submit the POC on their own form, but the POC must contain the elements listed in this section. A written or verbal physician approval of the POC from the ordering physician must be in place by the SOC. If the PPECC has a verbal approval of the POC at the time the prior authorization request is submitted, the dated documentation of this POC verbal approval must be submitted with the POC, followed by the physician-signed and dated POC within fourteen (14) calendar days from receipt by the Texas Medicaid Claims Administrator.
A completed Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form signed and dated by the ordering physician, RN completing the assessment, and client or client’s responsible adult. This completed form must include:
A written or verbal order for PPECC services from the ordering physician. A physician’s order (written or verbal) must be in place by the SOC. If the PPECC has a verbal order at the time the prior authorization request is submitted, dated documentation of this verbal order must be submitted separately, or it must be included on the POC.
Note:
For authorization purposes, a physician signature on the PPECC plan of care serves as the physician order. However, the physician order as outlined above must be maintained in the client’s medical records.
Signed and dated consent of the client or client’s responsible adult documenting his/her choice of PPECC services. The signed consent must include an acknowledgement by the client or the client’s responsible adult that he/she has been informed that their private duty nursing might be reduced as a result of accepting PPECC services. Consent to share the client’s personal health information with the client’s other providers to ensure coordination of care must also be obtained.
A client signature on the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers meets the client consent requirements.
The POC must be developed by a PPECC RN, in collaboration with an interdisciplinary team, in compliance with PPECC licensure requirements. The POC, using either the Prescribed Pediatric Extended Care (PPECC) POC form or a PPECC-developed form, must include the following components:
Therapies (occupational, physical, speech, and respiratory care), including how those therapies are accessed, amount, duration, and frequency. Therapies provided in the PPECC, as well as outside the PPECC (e.g., school based), must be documented.
Confirmation that a signed contingency plan is in place in circumstances when PPECC services are not available (e.g., fire, flood, windstorm, or electrical malfunctions), and for emergencies that occur while the client is in the care of the PPECC
List of services the client receives in the home and school settings. (e.g., ECI, therapies, school-based services (SHARS), PCS, PDN, therapies, skilled home health, case management services, hospice, and Medicaid waiver programs such as Medically Dependent Children’s Program (MDCP), Home and Community-Based Services (HCS), Deaf-Blind Multiples Disabilities (DBMD), Texas Home Living (Uxmal), and Community Living Assistance and Support Services (CLASS)).
Note:
Client-specific measure able goals, including, if receiving PDN, the goal of ensuring coordination of ongoing skilled nursing services with the PDN provider, if receiving PDN
The ordering physician, PPECC RN and client or client responsible adult signatures must be current. Current is defined as signed and dated within the 30 calendar day period before the SOC. The ordering physician’s dated signature must be within the fourteen (14) calendar day period following the receipt of the authorization request by the Texas Medicaid claims administrator, when services are initiated by verbal order. All the following documentation requires the ordering physician’s signature with date, the CCP Prior Authorization form, the Prescribed Pediatric Extended Care Center (PPECC) Plan of Care, and the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers.
If documentation is submitted solely with the ordering physician’s verbal order, it must be resubmitted with the ordering physician’s dated signature within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator.
If the request is not received with a dated physician signature within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator, the prior authorization will be considered incomplete and will be denied.
When there is documentation of a verbal order, if all required documentation is not signed and dated by the ordering physician and received by the Texas Medicaid Claims Administrator within fourteen (14) calendar days of the receipt of the authorization request, claims with dates of services prior to the receipt of the signed and dated documentation will be denied.
Requests for authorizations of PPECC services should always be commensurate with the client’s medical needs.
The length of the 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. PPECC services will not be authorized for more than 90 calendar days from the SOC for an initial authorization.
Note:
2.14.1.1.2
The PPECC provider may request a revision to the plan of care at any time during an authorization period. Requests for changes in the service hours during a current authorization period should be submitted if there is a change in the client’s condition, or the authorized services are not commensurate with the client’s medical needs and additional authorized hours are medically necessary.
Note:
Schedule changes that do not affect overall authorized ongoing skilled nursing hours do not require a revision authorization request, but must be documented in the client’s medical record.
Requests for revisions must be submitted to the Texas Medicaid Claims Administrator as soon as the PPECC identifies the need for a revision. Revision requests may be submitted by electronic portal, fax, or mail.
Requests for revisions must be submitted within three (3) business days of the revised SOC date. Requests received after the three (3) business days will be denied for dates of service that occurred before the request is received.
When a client’s condition changes during the course of the authorization period that impacts the amount or duration of services, a reassessment performed by a PPECC RN is required. A reassessment is not necessary if there is not a change in the client’s condition.
The PPECC provider must notify the Texas Medicaid Claims Administrator and the client’s ordering physician at any time during an authorization period if the client’s condition changes, the authorized services are not commensurate with the client’s medical needs, and the client requires additional hours of ongoing skilled nursing services. Submission of a revision authorization request, with physician signatures on required documentation, meets the notification requirement.
Revisions require all the following documentation:
An updated Prescribed Pediatric Extended Care Center (PPECC) Plan of Care form signed and dated by the ordering physician, the PPECC RN completing the POC, and client or client’s responsible adult. A PPECC may also submit the POC on its own form, but the POC must contain all required elements listed under Initial Authorizations in this section. A written or verbal physician approval of the POC from the ordering physician must be in place by the revised SOC. If the PPECC has a verbal approval of the POC at the time the prior authorization request is submitted, the dated documentation of this POC verbal approval must be submitted with the POC, followed by the physician signed and dated POC within fourteen (14) calendar days from the receipt of the authorization request by the Texas Medicaid Claims Administrator.
A completed Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form signed and dated by the ordering physician, RN completing the assessment, and client or client’s responsible adult. This completed form must include:
A written or verbal order for PPECC services from the ordering physician. A physician’s order (written or verbal) must be in place by the revised SOC. If the PPECC has a verbal order at the time the prior authorization request is submitted, dated documentation of this verbal order must be submitted separately or it must be included on the POC. The signed, dated order must be received within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator.
Note:
For authorization purposes, a physician signature on the PPECC plan of care serves as the physician order. However, the physician order, as detailed in "Initial Authorizations," must be maintained in the client’s medical records.
Signed and dated consent of the client or client’s responsible adult documenting his/her choice of PPECC services. The signed consent must include an acknowledgement by the client or the client’s responsible adult that he/she has been informed that their private duty nursing might be reduced as a result of accepting PPECC services. Consent to share the client’s personal health information with the client’s other providers to ensure coordination of care must also be obtained.
Note:
A client signature on the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers meets the client consent requirements.
The ordering physician, PPECC RN, and client or client responsible adult signatures must be current. Current is defined as signed and dated within the 30 calendar day period before the SOC. The ordering physician dated signature may be submitted within the fourteen (14) calendar day period following the receipt of the authorization request by the Texas Medicaid Claims Administrator. All the following revision documentation requires the ordering physician’s dated signature: the CCP Prior Authorization Request Form, the Prescribed Pediatric Extended Care Center (PPECC) Plan of Care, and the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers.
Revisions during a current authorization period must fall within that authorization period. If the revision is requested beyond the existing authorization period, the provider must request a recertification authorization and submit all required documentation for a recertification.
When there is a revision request, and documentation is submitted solely with the ordering physician’s verbal order, it must be resubmitted with the ordering physician’s signature and date within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator. If the request is not received with a dated physician signature within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator, the prior authorization will be considered incomplete and will be denied.
When there is documentation of a verbal order and all of the required documentation is not signed and dated by the ordering physician and received by TMHP within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator, claims with dates of services prior to receipt of the signed and dated documentation will be denied.
2.14.1.1.3
If a provider or client discontinues PPECC services during an existing prior authorized period and the client requests services through a new PPECC provider, the new PPECC provider must follow all of the processes and submit documentation required for an initial request, as well as the following:
A change of provider letter signed and dated by the client or the client’s responsible adult documenting the date the client ended PPECC services (effective date of the change) with the previous provider, the names of the previous and new providers, and an explanation of why providers were changed.
When the new provider submits an authorization request, including all required documentation for an initial request, it will be authorized for no more than 90 calendar days. Regardless of the number of provider changes, clients may not receive PPECC services beyond the limitations outlined in this section.
2.14.1.1.4
A recertification is a new authorization period that may be approved for up to a maximum of 180 calendar days when the client meets medical necessity criteria. Revision requests may be submitted by electronic portal, fax, or mail. The client or the client’s responsible adult, physician, and PPECC provider must agree in writing that the recertification is appropriate each certification period.
An updated nursing assessment must be performed by the PPECC RN no more than 30 calendar days before the current authorization period expires. If there is no change in the client’s condition, the POC must document medical necessity to support continued PPECC services.
A recertification request must be submitted no more than 30 calendar days and no fewer than seven (7) calendar days before a current authorization period will expire. Requests received after the current authorization expires will be denied for dates of service that occurred before the date the request is received. For the recertification request, the PPECC provider must submit the following documentation no more than 30 calendar days and no fewer than seven (7) calendar days before a current authorization period will expire:
A completed Prescribed Pediatric Extended Care Center (PPECC) Plan of Care form, signed and dated by the ordering physician, the PPECC RN completing the POC, and client or client’s responsible adult within 30 calendar days prior to the SOC date. A PPECC may also submit the POC on their own form, but the POC must contain the elements listed under "Initial Authorization Request" requirements in this section.
The PPECC provider is responsible for ensuring that the ordering physician reviews and signs the POC within 30 calendar days of the expiration of the authorization period and this documentation must be maintained in the client’s record.
A completed Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form signed and dated by the ordering physician, RN completing the assessment, and client or client’s responsible adult within 30 calendar days prior to the SOC date. The addendum must include an updated 24-hour nursing services flow sheet and if there are changes, an updated problem list, and updated rationale summary page, a contingency plan, and a signed physician and client acknowledgement.
Note:
For authorization purposes, a physician signature on the PPECC plan of care serves as the physician order. However, the physician order, with elements outlined in "Initial Authorization Requests," must be maintained in the client’s medical record.
Signed, dated consent of the client or client’s responsible adult documenting their choice of PPECC services. The signed consent must include an acknowledgement by the client or the client’s responsible adult that he/she has been informed that other services such as private duty nursing might be reduced as a result of accepting PPECC services. Signed and dated consent to share the client’s personal health information with the client’s other providers, as needed to ensure coordination of care, must also be obtained.
Note:
A client signature on the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers meets the client consent requirements.
The provider may request a revision of a recertification at any time during the recertification period. Revisions must follow the instructions outlined under Revisions in this section. The provider must notify the claims administrator at any time during a recertification period if the client’s condition changes and the authorized services are not commensurate with the client’s medical needs.
All authorization timelines apply to recertification.
2.14.1.1.5
Authorization for PPECC services will be terminated when:
After receiving PPECC services, the client opts to decline PPECC services and receive his or her services at home. The home health agency or independent provider offering these services must submit or update all required authorization documentation to the claims administrator.
2.14.1.1.6
Providers may appeal denials or modifications of requested PPECC services with documentation to support the medical necessity of the requested PPECC services.
Appeals must be submitted to the Medicaid Claims Administrator’s CCP department 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 claims administrators will go back no more than three (3) 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 the client’s responsible adult will be notified of any denial or modification of requested services and will be given information about how to appeal the claims administrator’s decision or request a fair hearing.
PPECC services may be denied when:
The client’s needs are not beyond the scope of services available through Medicaid Title XIX Home Health SN and/or HHA Services because the needs can be met on a part-time or intermittent basis through a visiting nurse.
Prior authorization requests must be submitted for processing to the Texas Medicaid Claims Administrator Prior Authorization Department (fee-for-service clients).
Note:
Clients enrolled in a managed care health plan may receive services from a PPECC. Prior authorization requests for these clients must be submitted solely to the client’s managed care organization.
2.14.1.1.7
In addition to documentation requirements outlined in the "Authorization Requirements" section, the following documentation requirements apply. Services not supported by documentation are subject to recoupment.
All services outlined in this section are subject to retrospective review to ensure that the documentation in the client’s medical record supports the medical necessity of the service(s) provided.
PPECCs must maintain documentation in the client’s medical record, including but not limited to the following:
The PPECC must provide documentation that the client or the client’s responsible adult has been informed about how care will be coordinated between the client’s providers (e.g., client signature on the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers).
The PPECC must maintain evidence in the medical record that client or the client’s responsible adult has been involved in the development of the POC. (e.g., client signature on the Prescribed Pediatric Extended Care Center [PPECC] Plan of Care).
Documentation of all discrepancies between the weekly service hours scheduled and the service hours provided. Examples include but are not limited to, doctor’s appointments; the PPECC was closed one day for unforeseen reasons; the child was hospitalized; or the client’s responsible adult was ill and could not provide services that he or she would normally provide.
To complete a prior authorization process by paper, the provider must complete and submit the prior authorization documentation through fax or mail and must maintain a copy of the prior authorization request and all submitted documentation in the client’s medical record at the PPECC’s place of business.
To complete a prior authorization process electronically, the provider must complete and submit the prior authorization documentation through any approved electronic method, and must maintain a copy of the prior authorization request and all submitted documentation in the client’s medical record at the PPECC’s place of business.
The ordering physician must also maintain a copy of the signed and dated physician order and signed and dated POC in the client’s medical record.
PPECC service providers must provide written notice to clients of their intent to voluntarily terminate PPECC services at least fifteen (15) calendar days prior to terminating services, except in situations of a potential threat to the provider’s personal safety.
The PPECC must sign, date, and indicate the time the client is boarded on PPECC transportation, and the time when the client arrives at the PPECC. The PPECC must also sign, date, and indicate the time when the client is boarded for a return trip from PPECC services, as well as the arrival time at the client’s destination. The PPECC provider may use any reliable method to record times, dates, and signatures provided that it is accurate and allows for an auditable review of the records, including electronic census, time-stamp, scanning, and signature records.
For any Medicaid client that is in transport for longer than one hour, the PPECC must document the reason for the extended time in transport.
A responsible adult must sign and confirm the time that the client is boarded on PPECC transportation, as well as when a client returns from the PPECC. If a responsible adult provides the transportation, the responsible adult must sign and indicate the date and time that the client is dropped off and picked up from a PPECC. The PPECC provider must keep these records in case of an audit or monitoring.
A responsible adult must be provided daily a written, one-page summary of services provided to the client for each day that the client is in the PPECC’s care.
The PPECC must maintain documentation in the client’s medical record of the notification provided to the client and/or the client’s responsible adult of an intent to transfer or discharge the client as follows:
The PPECC and the therapy provider must have a written agreement for each client regarding the provision of therapy services when therapy services (occupational, speech, physical, and respiratory care) are provided at the PPECC. The written agreement must address responsibilities of both parties, and how the parties will coordinate related to the client’s plan of care. The written agreement must be kept in the client’s medical record.
The PPECC and hospice provider must have a written agreement for each client regarding the provision of hospice services when hospice is provided at the PPECC. The written agreement must address responsibilities of both parties, and how the parties will coordinate related to the client’s plan of care. The written agreement must be kept in the client’s medical record.
2.14.1.1.8
The services that are not covered by the PPECC benefit include the following:
Private duty nursing, skilled nursing and home health aid services provided in the home setting when medically needed in addition to the PPECC services authorized.
2.14.1.1.9
PPECC services may be reimbursed when billed with procedure codes T1025, T1026, or T2002.
Services begin when the PPECC assumes responsibility for the care of the client (i.e., the point the client boards the PPECC transportation, or when the client is brought to the PPECC by a responsible adult) and ends when the care is relinquished to the client’s responsible adult.
Providers must use appropriate procedure codes for the PPECC services performed. Procedure codes T1025 and T2002 are limited to once per day.
The PPECC per diem code (T1025) and hourly procedure code (T1026) may not be billed on the same day.
Procedure code T1026 is allowed on an hourly basis, up to four hours. Services beyond four hours must be billed using T1025. At a minimum, four hours and fifteen minutes of services must be provided before T1025 may be billed.
Procedure code T2002 is not allowed without a PPECC service on the same day, same provider.
For procedure code T1026, a minimum of 15 minutes of service is required to round up to a full hour after the first hour.
Therapy services are billed separately by Medicaid-enrolled licensed therapists, including ECI providers, and are subject to prior authorization and policies governing Physical, Occupational, and Speech Therapy - Children (Acute and Chronic), or ECI services, as applicable.
If hospice services are rendered in a PPECC setting, they must be billed separately by Medicaid-enrolled hospice providers, and are subject to prior authorization and policies governing hospice reimbursement.
The following services may be billed on the same day as PPECC services, but they may not be billed simultaneously with PPECC services. These services may be billed before or after PPECC services:
PCS services provided in a PPECC are considered part of the PPECC billable rate. PCS services rendered in a client’s home may be billed before or after PPECC services on the same day.
PPECC services may be reimbursed only to a licensed PPECC.
Note:
Texas Medicaid will not reimburse PPECC services that duplicate services that are the legal responsibility of the school districts. The school district, through the SHARS program, is required to meet the client’s skilled nursing needs while the client is at school. However, if those needs cannot be met by SHARS or the school district, documentation supporting medical necessity may be submitted to the Texas Medicaid Claims Administrator.
Parental accompaniment is not required for PPECC reimbursement.
Non-emergency ambulance service providers will not be reimbursed for transportation to and from a PPECC.
PPECC services are subject to retrospective review and possible recoupment when the medical record does not document the provision of PPECC services is medically necessary based on the client’s situation and needs. The PPECC provider must explain all discrepancies between the service hours approved and the service hours provided. For example: The parents withdrew their client from a PPECC and released the provider from all responsibility for the service hours; the PPECC was closed one day for unforeseen reasons; the client was hospitalized; or the responsible adult was ill and could not provide services that he or she would normally provide.
Payment will not be rendered for services that are not prior authorized.

Texas Medicaid & Healthcare Partnership
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