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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 : * Prior Authorization of PDN Services
Prior authorization requests may be submitted to the TMHP Prior Authorization Department by mail, fax, or the electronic portal. Prescribing or ordering providers, dispensing providers, clients’ responsible adults, and clients may sign prior authorization forms and supporting documentation using electronic or wet signatures. For additional information about electronic signatures, please refer to the ’Electronic Signatures in Prior Authorizations’ medical policy.
PDN services require prior authorization. Providers must obtain authorization within three business days of the SOC for services that have not been prior authorized. During the authorization process, providers are required to deliver the requested services from the SOC date. The SOC date is the date agreed upon by the physician, the PDN provider, and the client, parent, or guardian and is indicated on the submitted POC as the SOC date.
Not including PDN services provided during the authorization process, coverage periods may not coincide with calendar weeks or months. A prior authorized week coverage period begins from the day of the week the prior authorization period begins on and continues for seven days. For example, if the prior authorization starts on a Thursday, the prior authorization week runs Thursday through Wednesday. The number of nursing hours authorized for a week must be contained in that prior authorization week. Hours billed in excess of those authorized for the PAN week are subject to recoupment.
A PDN provider requesting prior authorization for PDN services must submit all of the following documentation:
A completed Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form signed and dated by the primary physician, RN completing the assessment, and client, parent, guardian, or responsible adult within 30 calendar days prior to the SOC date. The Nursing Addendum form must include:
All documentation must be maintained by the requesting PDN provider. The PDN provider may be asked to submit additional documentation to support medical necessity as defined in this policy.
The request can be submitted as follows:
To complete the prior authorization process by paper, the PDN provider must fax or mail the completed PDN Request Documentation to the CCP prior authorization unit and retain a copy of the signed and dated documentation in the client’s medical record at the provider’s place of business.
To complete the prior authorization process electronically, the PDN provider must complete the prior authorization requirements through any approved electronic methods and retain a copy of the signed and dated documentation in the client’s medical record at the provider’s place of business.
Requests for authorizations of PDN services should always be commensurate with the client’s medical needs. Requests for services should reflect changes in the client’s condition that affect the amount and duration of PDN.
For clients who are receiving PDN services who also require phototherapy, parent or guardian education, instructional use of the phototherapy equipment, and obtaining laboratory specimens collection are included in the PDN care provided.
Authorizations for more than 16 hours per day will not be issued to a single, independently enrolled nurse.
The length of the authorization is determined on an individual basis and is based on the goals and timelines identified by the physician, provider, and client, parent, or guardian. PDN services will not be authorized for more than six months at a time.
The claims administrator is required to notify the client, parent, or guardian, physician, and provider of the approval, denial, or other action taken in response to the authorization request by fax or mail.
Home Health Agencies must provide written notice to clients of their intent to voluntarily terminate PDN services at least five calendar days prior to terminating services, except in situations of a potential threat to the provider’s personal safety.
Independently enrolled RNs or LVNs must provide written notice to clients of his or her intent to voluntarily terminate services at least 30 calendar days prior to terminating services, except in situations where there is a potential threat to the nurse’s personal safety.
For clients who are receiving PDN services who also require TPN administration education, intermittent SN visits may be separately authorized when the SN services are for client or client caregiver training in TPN administration, and the PDN provider is not an RN appropriately trained in the administration of TPN, and the PDN provider is not able to perform the function.
Refer to:
Subsection 3.3, “* Home Health Skilled Nursing and Home Health Aide Services Providers” in this handbook for detailed information about SN benefits.
If the client has no skilled nursing need other than provision of education for self administration of prescribed injections (IM, SQ, or IV), then the client does not qualify for private duty nursing services. Nursing hours for the sole purpose of education to the client and caregiver may be considered through intermittent home health skilled nursing visits.

Texas Medicaid & Healthcare Partnership
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