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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 : 4.1.4.13 Appeal of Authorization Decisions

4.1.4.13
Providers may appeal denials or modifications of requested PDN services with documentation to support the medical necessity of the requested PDN services. Appeals must be submitted to the claims administrator’s CCP department with complete documentation and any additional information within two weeks of the date on the decision letter. If changes are made to the authorization based on this documentation, CCP claims administrator’s will go back no more than three business days for initial, or revision requests and no more than seven calendar days for recertification requests when additional documentation is submitted.
The client, parent, or guardian will be notified of any denial or modification of requested services and will be given information about how to appeal the claims administrator’s decision.
All documentation must be submitted together, and requests are not reviewed until all documentation is received. If complete documentation is received at CCP by 3 p.m., Central Time, a response is returned to the provider within one business day. Complete documentation for initial, revision, recertification, and extension requests for PDN authorizations include all of the following:

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