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December 2016 Texas Medicaid Provider Procedures Manual

Home Health Nursing and Private Duty Nursing Services Handbook

Home Health Nursing and Private Duty Nursing Services Handbook
Table of Contents
1 General Information 4
1.1 Client Eligibility for Home Health Nursing and Aide Services 4
1.1.1 Prior Authorization Requests for Clients with Retroactive Eligibility 5
1.1.2 Client Evaluation 5
1.2 Client Eligibility for PDN Services 5
2 Enrollment 6
3 Home Health Skilled Nursing and Home Health Aide Services 6
3.1 * Services, Benefits, Limitations, and Prior Authorization 6
3.1.1 Medical Necessity 7
3.2 Skilled Nursing and Home Health Aide Services 7
3.2.1 Skilled Nursing Visits 8
3.2.2 Home Health Aide Visits 10
3.2.2.1 Supervision of Home Health Aides 10
3.3 * Home Health Skilled Nursing and Home Health Aide Services Providers 11
3.4 * Authorization Requirements 11
3.4.1 * Initial Assessment and Reassessments 12
3.4.2 * Home Health Services Plan of Care Requirements 13
3.4.2.1 Written Plan of Care (POC) 15
3.4.2.2 DME and Medical Supplies Submitted with a Plan of Care (POC) 15
3.4.3 Prior Authorization of SN and HHA Services 16
3.4.3.1 Routine Laboratory Specimens 16
3.4.3.2 Home Phototherapy 17
3.4.3.3 Prothrombin Time/Internationalized Normalized Ration (TP/INR) Home Testing Device 17
3.4.3.4 Total Parenteral Nutrition (TPN) 17
3.4.3.5 Instruction in the Self-administration of Prescribed Injections 17
3.4.3.6 Prior Authorization Status and Limitations 18
3.4.3.7 Canceling a Prior Authorization 18
3.4.4 Medicare and Medicaid Prior Authorization 18
3.5 * Home Health SN and HHA Procedure Billing and Limitations 20
3.5.1 * Skilled Nursing Visit for TPN Education 21
3.5.2 Medication Administration Limitations 21
4 Private Duty Nursing (PDN) Services - CCP 22
4.1 * Services, Benefits, Limitations, and Prior Authorization 22
4.1.1 Medical Necessity 23
4.1.2 * PDN Services 23
4.1.3 * PDN Providers 25
4.1.4 Authorization Requirements 26
4.1.4.1 Authorization Forms 27
4.1.4.2 * Primary Physician Requirements 28
4.1.4.3 PDN Provider Requirements 30
4.1.4.4 * Prior Authorization of PDN Services 30
4.1.4.5 * Initial Authorization 32
4.1.4.6 * Revisions 32
4.1.4.7 * Required Coordination between PDN and Prescribed Pediatric Extended Care Centers (PPECCs) 33
4.1.4.8 * Client Receives both PDN and PPECC and Shifts Services from One to the Other 34
4.1.4.9 * Recertifications 34
4.1.4.10 Special Circumstances 35
4.1.4.11 PDN Services Provided in Group Settings 35
4.1.4.12 Termination of Authorization 36
4.1.4.13 Appeal of Authorization Decisions 36
4.1.4.14 Start of Care (SOC) 36
4.1.4.15 Client and Provider Notification 37
4.1.5 Procedure Codes and Limitations 37
4.1.5.1 * PDN Services 37
4.1.5.2 PDN Provided During a Skilled Nursing Visit for TPN Administration Education 38
5 Documentation Requirements 38
6 Claims Filing and Reimbursement 39
6.1 Claims Filing 39
6.1.1 * Home Health Skilled Nursing and Home Health Aide Providers 40
6.1.2 PDN Providers 40
6.2 Reimbursement 40
 

Texas Medicaid & Healthcare Partnership
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