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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 : Prior Authorization Status and Limitations
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.
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A prior authorization for SN or HHA visits is no longer valid when: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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