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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 : 3.4.3 Prior Authorization of SN and HHA Services : 3.4.3.6 Prior Authorization Status and Limitations

3.4.3.6
The claims administrator will notify the provider of the authorization or other action taken on the request for services.
Up to a maximum combined total of three SN and HHA visits may be prior authorized per day. One visit may last up to a maximum of 2.5 hours. SN or HHA visits may be provided on consecutive days.
Note:
When documentation does not support medical necessity for home health SN or HHA visits, providers may be directed to possible alternative services based on the client’s age and needs.
A nurse or HHA may be authorized to provide services to more than one client over the span of the day as long as:
Settings in which a nurse or HHA provider may provide services in a provider-client ratio greater than 1:1 include, but are not limited to, homes with more than one client receiving home health services, foster homes, and independent living arrangements.
A prior authorization for SN or HHA visits is no longer valid when:
The client, parent, guardian, or caregiver refuses to comply with the attending physician’s plan of treatment and compliance is necessary to assure the health and safety of the client; or
The client changes providers and the change of notification is submitted to the claims administrator in writing with a prior authorization request from the new provider.

Texas Medicaid & Healthcare Partnership
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