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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 : 4.1.4.5 * Initial Authorization

4.1.4.5
An initial PDN prior authorization request requires 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 completed Nursing Addendum form must include all the following:
Note:
An advanced practice registered nurse (APRN) or a physician assistant (PA) may sign all documentation related to the provision of private duty nursing services on behalf of the client’s physician when the physician delegates this authority to the APRN or PA.
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.
Initial requests must be submitted within three business days of the SOC date.
Initial requests may be prior authorized for a maximum of 90 days.
Completed initial requests must be received and dated by CCP within three business days of the SOC. The request must be received by CCP no later than 5 p.m., Central Time, on the third day to be considered received within three business days. If a request is received more than three business days after the SOC, or after 5 p.m., Central Time, on the third day, authorization is given for dates of service beginning three business days before receipt of the completed request.

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