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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 : 4.1.4.9 * Recertifications

4.1.4.9
Recertifications may be prior authorized for up to a maximum of six months.
The following criteria must be met before a client receives a recertification:
A recertification request must be submitted at least 7 calendar days before, but no more than 30 days before, a current authorization period will expire. The PDN provider must submit the following documentation with the recertification request:
A completed THSteps-CCP Private Duty Nursing six-month authorization signed and dated by the primary physician, nurse provider, and client, parent, or guardian
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.
The provider is responsible for ensuring that the physician reviews and signs the POC within 30 calendar days of the expiration of the authorization period, and this documentation must be maintained in the client’s record. PDN providers should not submit a revised POC unless requesting a revision.
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.
The provider may request a revision of a recertification at any time during the recertification period if medically necessary. The provider must notify the claims administrator at any time during a recertification period if the client’s condition changes and the authorized services are not commensurate with the client’s medical needs.
All authorization timelines apply to recertifications.
Completed extension requests must be received and dated by CCP at least seven calendar days before, but no more than 30 days before, the current authorization expiration date. The request must be received by CCP no later than 5 p.m., Central Time, on the seventh day, to be considered received within seven calendar days. If a request is received less than seven calendar days before the current authorization expiration date, or after 5 p.m., Central Time, on the seventh day, authorization is given for dates of service beginning no sooner than seven calendar days after the receipt of the completed request by CCP.
The nursing care provider must notify CCP at any time during the authorization period if the client’s condition and need for SN care significantly changes.

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