Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.
Important: Texas Medicaid MCOs must follow all the requirements for Medicaid private duty nursing (PDN) services outlined in the Texas Medicaid Provider Procedures Manual (TMPPM).
Effective for dates of service on or after November 1, 2025, Texas Medicaid will update certain PDN benefit information.
Overview of PDN Benefit Clarifications
Changes to the benefit information include clarification for the following:
- General prior authorization information
- Prior authorization requirements for specialized care
- Reimbursement guidelines
General Prior Authorization Updates
The primary physician must include the settings or modes for required equipment (e.g., ventilator, oxygen) in the physician-recommended plan of care (POC).
Providers can refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Home Health Nursing and Private Duty Nursing Services Handbook, subsection 4.1.4.2, “Primary Physician Requirements,” for additional POC requirements.
Texas Medicaid may approve prior authorization requests as follows:
- Up to 180 calendar days at a time for PDN services
- Up to 180 calendar days for revised services. If a client does not meet the criteria for the 180-day authorization, Texas Medicaid may approve revision requests for up to 90 calendar days.
Texas Medicaid may authorize recertifications for up to 180 calendar days if the client meets all the following criteria:
- The client received PDN services for at least 90 calendar days.
- The client experienced no significant changes in their condition for at least 90 calendar days.
- The provider is not expecting any significant changes in the client’s condition.
- The client’s parent or guardian, physician, and provider agree that the recertification is appropriate.
Specialized Care
Texas Medicaid may provide additional reimbursement for clients who require specialized care due to their dependence on invasive ventilator life support or the presence of a functioning tracheostomy. Invasive mechanical ventilation refers to the delivery of positive pressure to the lungs through an endotracheal or tracheostomy tube.
A client who is dependent on a ventilator cannot breathe without assistance and requires invasive ventilator support.
To receive additional reimbursement for this specialized care, the PDN provider must include procedure code T1000 with modifier UA on new prior authorization requests for PDN services beginning November 1, 2025.
Providers with existing PDN prior authorizations for dates of service that occur on, after, or encompass November 1, 2025, must contact the Texas Medicaid & Healthcare Partnership (TMHP) Prior Authorization Department to update prior authorizations for clients who require specialized care.
Prior Authorization Criteria for Specialized Care
The PDN provider must use the CCP Prior Authorization Request Form for all prior authorization requests, and the form must include the following:
- Procedure code T1000 with modifier UA
- A brief description of the requested services
- Documentation of medical necessity
Note: Documentation of medical necessity must also be included on the Home Health Plan of Care (POC) and the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers forms.
PDN providers that request prior authorization for specialized care (procedure code T1000 with modifier UA) must submit all the documentation required for PDN services. They must also submit the clinical indications, as supported by a physician’s order and documented in the Home Health POC, that justify the specialized care. Clinical indications for specialized care include the following:
- Clients who require a home ventilator with invasive interface (e.g., tracheostomy) associated with one of the following:
- Neuromuscular disease
- Thoracic restrictive disease
- Chronic respiratory failure consequent to chronic obstructive pulmonary disease
- Congenital central hypoventilation syndrome
- Chronic lung disease of infancy (e.g., bronchopulmonary dysplasia)
- Obesity hypoventilation syndrome
- Restrictive disorder of chest wall
- Other conditions requiring invasive ventilation supported with documentation of medical necessity by a physician
Clients with a functioning tracheostomy requiring both suctioning and other specified types of nursing care (e.g., dressing changes, skin care, humidification, or changing tracheostomy tubes and ties). Documentation in the treatment plan must include specific interventions and care.
Note: Texas Medicaid will not approve a request for specialized care if the client has a tracheostomy but does not meet the above requirements.
Texas Medicaid will not approve clients with the following clinical indications for specialized care:
- Clients who use a non-invasive ventilator
- Clients who use a ventilator exclusively to function as a respiratory assistance device, including continuous positive airway pressure (CPAP), auto-titrating positive airway pressure (PAP), bilevel positive airway pressure (BPAP, BiPAP), or adaptive servo-ventilation
Note: Texas Medicaid will still consider prior authorization for PDN services even if Texas Medicaid does not approve the services for specialized care.
Clarification of Certain Reimbursement Guidelines
Providers must bill all hours worked on a single calendar day together on one detail line. If a nurse’s shift spans two calendar days—such as from 7 p.m. to 7 a.m.—they must bill the services on two separate detail lines, for instance:
- The first detail: 7:00 p.m. to 11:59 p.m. (20 units of 15 minutes each)
- The second detail: 12:00 a.m. to 7:00 a.m. (28 units of 15 minutes each)
Claims for PDN services will not be reimbursed when they are submitted by:
- A parent or guardian of a minor client.
- The client’s spouse—even if they are an enrolled provider, employed by an enrolled provider, or an owner of a home health agency.
For more information, call the TMHP Contact Center at 800-925-9126.