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December 2016 Texas Medicaid Provider Procedures Manual

Home Health Nursing and Private Duty Nursing Services Handbook : 4 Private Duty Nursing (PDN) Services - CCP : 4.1 * Services, Benefits, Limitations, and Prior Authorization : 4.1.4 Authorization Requirements

4.1.4
PDN services require prior authorization.
All requests for PDN services must be based on the current medical needs of the client.
PDN services will not be prior authorized when:
When the client’s needs are not beyond the scope of services available through Medicaid Title XIX Home Health SN or HHA Services because the needs can be met on a part-time or intermittent basis.
Requests for PDN must be based on the current medical needs of the client.
The following criteria are considered for PDN prior authorization:
The explanation of the client’s medical needs is sufficient to support a determination that the requested services correct or ameliorate the client’s disability, physical or mental illness, or chronic condition.
The client’s nursing needs cannot be met on an intermittent or part-time basis through Texas Medicaid (Title XIX) home health services skilled nursing services.
Only those services that CCP determines to meet the medical necessity criteria for PDN are reimbursed. Before CCP determines the requested nursing services do not meet the criteria, the TMHP Medical Director contacts the treating physician to determine whether additional information or clarification can be provided that would allow for the prior authorization of the requested PDN. If the TMHP Medical Director is not successful in contacting the treating physician or cannot obtain additional information or clarification, the TMHP Medical Director makes a decision based on the available information.
Providers must obtain prior authorization within three calendar days of the SOC for services that have not been prior authorized. During the prior authorization process, providers are required to deliver the requested services from the SOC date. The SOC date is the date agreed to by the physician, the PDN provider, and the client or responsible adult and is indicated on the submitted POC as the SOC date.
Note:
Requests for nursing services must be submitted on the required Medicaid authorization forms and include supporting documentation. The supporting documentation must:

Texas Medicaid & Healthcare Partnership
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