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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 : 4.1.4.6 * Revisions

4.1.4.6
The provider may request a revision at any time during the authorization period if medically necessary. The provider must notify the claims administrator at any time during an authorization period if the client’s condition changes and the authorized services are not commensurate with the client’s medical needs.
Requests for revisions must be submitted within three business days of the revised SOC date.
Revisions during a current authorization period must fall within that authorization period. If the revision is requested outside of an authorization period, the provider must request a new authorization and submit 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 parent, guardian, client, or responsible adult within 30 calendar days prior to the SOC date.
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.
Revised services may be prior authorized for up to a maximum of six months.
A request for a client that does not satisfy the criteria listed above for a six-month authorization may be authorized for a period up to three months.
The provider is responsible for ensuring that the physician reviews and signs the POC within 30 calendar days of the start date of the revised authorization period, or more often if required by the client’s condition or agency licensure. The provider must maintain the physician-signed POC in the client’s record. PDN providers should not submit a revised POC unless they are requesting a revision.
Completed requests for revision of PDN hours during the current authorization period must be received by CCP within three business days of the revised SOC. The request must be received by CCP no later than 5 p.m., Central Time, on the seventh day to be considered received within three business days. If a request is received more than three business days after the revised 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.
Revisions to a current certification must fall within the certification period. If the revision extends beyond the current certification period, new authorization documentation must be submitted to CCP.

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