Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Home Health Nursing and Private Duty Nursing Services Handbook : 3 Home Health Skilled Nursing and Home Health Aide Services : 3.4 * Authorization Requirements

3.4
Home Health SN and HHA visits require prior authorization.
Prior authorization of SN or HHA visits, requires that a client’s primary physician:
Provides an order for SN or HHA visits or recertification, identifying that the prescribed SN or HHA visits are medically necessary as defined in the Statement of Benefits
The physician’s documentation in the client’s medical record must support the prescribed SN or HHA visits are medically necessary as defined in the Statement of Benefits
The physician’s documentation in the client’s medical record must support that the client’s medical condition is sufficiently stable to permit safe delivery of SN or HHA visits as described in the home health services POC
Reviews and approves the home health services POC at least every 60 days, or more frequently as the physician determines necessary, including but not limited to when the client’s condition changes
SN visits requested primarily to provide the following will not be prior authorized:
Note:
Clients who are 20 years of age or younger may be eligible for private duty nursing services and personal care services through Texas Medicaid Private Duty Nursing Services and Personal Care Services Policies.
HHA visits requested for the following will not be prior authorized when:
Note:
Clients who are 20 years of age or younger may be eligible for private duty nursing services and personal care services through Private Duty Nursing (PDN) Services - THSteps-CCP Policy or Personal Care Services (PCS) - THSteps-CCP).
Certain facilities are required by licensure to meet all the medical needs of the client. SN or HHA visits will not be authorized for clients receiving care in any of the following facilities:
When a client, client’s responsible adult, or client’s physician notifies the SN and/or HHA service provider that the client also receives services from a PPECC, the SN and/or HHA service provider must coordinate services with the PPECC provider to prevent duplication of services.
Note:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.