Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.06-030 - Private Duty Nursing Update Transmittal #68
Current through Register Vol. 49, No. 9, September, 2024
Section II Private Duty Nursing Services
Providers of Private Duty Nursing Services (PDN) must meet the following criteria in order to be eligible for participation in the Arkansas Medicaid Program:
Providers who have agreements with Medicaid to provide other services to Medicaid beneficiaries must have a separate provider application and Medicaid contract to provide private duty nursing services. A separate provider number is assigned.
Arkansas Medicaid will enroll Arkansas school districts and Education Service Cooperatives (ESC) as Private Duty Nursing Services (PDN) providers when the following criteria are met:
DHHS requires retention of all records for five (5) years. Providers of Private Duty Nursing Services (PDN) must keep and make available to authorized representatives of the Arkansas Division of Medical Services, the State Medicaid Fraud Control Unit, representatives of the Department of Health and Human Services and its authorized agents or officials, records which include:
Failure to furnish records upon request may result in sanctions.
The Arkansas Medicaid Program is designed to assist eligible Medicaid beneficiaries in obtaining medical care within the guidelines specified in this manual.
Private duty nursing services are those medically necessary services that are provided by a registered nurse or licensed practical nurse under the direction of the beneficiary's physician, to a beneficiary in his or her place of residence, a Division of Developmental Disabilities Services (DDS) community provider facility or a public school. For purposes of the Medicaid program, private duty nursing services are those medically necessary services related to the coverage described in Section 213.000 and delivered by a registered nurse or licensed practical nurse, as required by the State Nurse Practice Act. The registered nurse or licensed practical nurse providing services may not be a family member or taking on the role of a family member of the Medicaid beneficiary as described in Section 212.100.
Private Duty Nursing Services (PDN) may be covered for individuals who meet the following requirements:
PDN services may be provided by a registered nurse and/or licensed practical nurse as directed by the beneficiary's physician.
All PDN services require prior authorization by the Medicaid Program. Refer to Section 220.000 of this manual for information on the prior authorization process.
The Arkansas Medicaid Program covers Private Duty Nursing Services (PDN) medical supplies. Supplies are limited to $80.00 per month, per beneficiary.
Refer to Section 242.130 of this manual for PDN nursing supplies.
The following medical criteria and guidelines are utilized in evaluating coverage of private duty nursing services for a ventilator-dependent beneficiary:
Specific factors to be assessed:
Major commitments on the part of the child's family and community are mandatory to meet the child's extraordinary needs. Specific components include:
Private duty nursing services will not be authorized for a beneficiary in a boarding home, hospital, nursing facility, residential care facility or any other institutional setting or health care facility.
A request for prior authorization for private duty nursing services must originate with the provider. The provider is responsible for completion of the Request for Private Duty Nursing Services Prior Authorization and Prescription Initial Request or Recertification (form DMS-2692) and obtaining the required medical information. Form DMS-2692 must be signed by the beneficiary's physician with documentation that a physical examination was performed within 12 months of the beginning of the initial request or the recertification. View or print form DMS-2692 and instructions for completion.
For PDN services in the beneficiary's home a social/environmental evaluation indicating a commitment on the part of the beneficiary's family to provide a stable and supportive home environment must accompany the request for prior authorization. Refer to Section 224.000 of this manual for additional information required for the initial request.
All PA requests for Medicaid-eligible beneficiaries will be evaluated by the Division of Medical Services, Utilization Review (UR) Section, to determine the level of care and amount of nursing services to be authorized. View or print Utilization Review Section contact information.
The UR Section will notify the provider of the approval or denial of the PDN services PA request within 15 working days following the receipt of the PA request. If the PA request for PDN services is approved, page 5 of form DMS-2692 will be returned to the provider with the number of hours approved indicated on the form. The PA number will be assigned after the provider sends in documentation of the actual hours worked.
NOTE: The prior authorization number MUST be entered on the claim form filed for payment of these services. The initial PA approval will only be authorized for a maximum of 90 days. A new request must be made for services needed for a longer period of time. Recertification may be authorized for a maximum of six (6) months. Refer to Section 224.000 of this manual for information regarding recertification of PDN services. The effective date of the PA will be the date the patient begins receiving PDN services or the day following the last day of the previous PA approval.
Providers are cautioned that a prior authorization approval does not guarantee payment. Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time service is provided and upon completeness and timeliness of the claim filed for the service. The provider is responsible for verifying the beneficiary's eligibility.
To request prior authorization, the Private Duty Nursing Services (PDN) provider must complete and forward the original and one copy of Form DMS-2692 to the Division of Medical Services Utilization Review Section. View or print the DMS Utilization Review Section contact information.
A copy of the form should be retained in the provider's records.
Additional documentation is required for PDN services for eligible Medicaid beneficiaries under age 21. The following documentation must be provided:
View or print form CMS-485.
New requests for PDN services should be sent to the Division of Medical Services, Utilization Review Section (UR) as early as possible after the medical need for private duty nursing is identified.
Providers must submit requests for prior authorization of PDN services within 30 days of the beginning date of service. Providers assume the risk of services ultimately being found not medically necessary. When PDN services are approved by UR at the level requested, the effective date of the prior authorization will be retroactive to the beginning date of service.
Please see section 190.000 et al for information regarding administrative appeals.
A provider may request reconsideration of a Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Health and Human Services (DHHS) Management Staff, who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
Private Duty Nursing providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.
Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.
The following HCPCS procedure codes must be used when billing the Arkansas Medicaid Program for medical supplies.
A4206 |
A4216 |
A4217 |
A4221 |
A4222 |
A4253 |
A4256 |
A4259 |
A4265 |
A4310 |
A4311 |
A4312 |
A4313 |
A4314 |
A4315 |
A4316 |
A4320 |
A4322 |
A4326 |
A4327 |
A4328 |
A4330 |
A4338 |
A4340 |
A4344 |
A4346 |
A4347 |
A4348 |
A4351 |
A4352 |
A4354 |
A4355 |
A4356 |
A4357 |
A4358 |
A4359 |
A4361 |
A4362 |
A4364 |
A4367 |
A4369 |
A4371 |
A4397 |
A4398 |
A4399 |
A4400 |
A4402 |
A4404 |
A4405 |
A4406 |
A4414 |
A4452 |
A4454 |
A4455 |
A4558 |
A4560 |
A4561 |
A4562 |
A4623 |
A4624 |
A4625 |
A4626 |
A4628 |
A4629 |
A4772 |
A4927 |
A5051 |
A5052 |
A5053 |
A5054 |
A5055 |
A5061 |
A5062 |
A5063 |
A5071 |
A5072 |
A5073 |
A5081 |
A5082 |
A5093 |
A5102 |
A5105 |
A5112 |
A5113 |
A5114 |
A5119 |
A5121 |
A5122 |
A5126 |
A5131 |
A6154 |
A6234 |
A6241 |
A6242 |
A6248 |
A6441 |
A6442 |
A6443 |
A6444 |
A6445 |
A6446 |
A6447 |
A6448 |
A6449 |
A6450 |
A6451 |
A6452 |
A6453 |
A6454 |
A6455 |
A7520 |
A7521 |
A7522 |
A7524 |
A7525 |
B4086 |
B4100 |
E0776 |
National HCPCS Codes
Procedure Code |
Required Modifier |
Description |
A6257 |
Transparent Film, each (16 square inches or less) |
|
A6258 |
Transparent Film, each (more than 16, but less than 48 square inches) |
|
A6259 |
Transparent Film, each (more than 48 square inches) |
|
A6216 A6219 A6228 |
Gauze Pad, Medicated or Non-Medicated, each (16 square inches or less) |
|
A6220 A6229 A6217 |
Gauze Pads, Medicated or Non-Medicated, each (more than 16, but less than 48 square inches) |
|
A6221 A6230 A6218 |
Gauze Pads, Medicated or Non-Medicated, each (more than 48 square inches) |
|
A4450 |
Gauze, Non-Elastic, Per Roll (1 linear yard) |
|
A6245 A6242 |
Hydro gel Dressing, each (16 square inches or less) |
|
A6246 |
Hydro gel Dressing, each (more than 16, but less than 48 square inches) |
|
A6247 A6244 |
Hydro gel Dressing, each (more than 48 square inches) |
|
A6248 |
Hydro gel Dressing, each (1 ounce) |
|
A6237 A6234 |
Hydrocolloid Dressing, each (16 square inches or less) |
|
A6238 A6235 |
Hydrocolloid Dressing, each (more than 16, but less than 48 square inches) |
|
A6236 A6239 |
Hydrocolloid Dressing, each (more than 48 square inches) |
|
A6196 |
Alginate Dressing, each (16 square inches or less) |
|
A6197 |
Alginate Dressing, each (more than 16, but less than 48 square inches) |
|
A6198 |
Alginate Dressing, each (more than 48 square inches) |
|
A6197 |
UB |
Alginate Dressing, each (1 linear yard) |
A6209 |
Foam Dressing, each (16 square inches or less) |
|
A6210 |
Foam Dressing, each (more than 16, but less than 48 square inches) |
|
A6211 |
Foam Dressing, each (more than 48 square inches) |
|
A6200 |
Composite Dressing, each (16 square inches or less) |
National HCPCS Codes
Procedure Code |
Required Modifier |
Description |
A6201 |
Composite Dressing, each (more than 16, but less than 48 square inches) |
|
A6202 |
Composite Dressing, each (more than 48 square inches) |
|
A4253 |
UB |
Blood Glucose test or reagent strip for home blood glucose monitor, per 25 strips |
A4353 |
Urinary intermittent catheter with insertion tray |
|
A4394 |
Ostomy deodorant, all types, per ounce |
|
A4365 |
Adhesive remover wipes, 50 per box |
|
A4368 |
Ostomy filters, any type, each |
|
A4483 |
Tracheostomy vent-heat moisture device |
|
L8239* |
Stocking (Jobst) |
|
A6549* |
Gradient compression stocking, not otherwise specified |
* Refer to section 242.430.
Place of Service |
Paper Claims |
Electronic Claims |
Patient's home |
4 |
12 |
DDS Facility (for beneficiaries under age 21, not school age) |
5 |
52 |
Public School (for beneficiaries under age 21) |
S |
03 |
Type of Service (paper only)
1-Private Duty Nursing Services
S-Public School (for beneficiaries under age 21) NOTE: Type of service code "S" requires the LEA number of the school district in Field 19 of the CMS-1500.
Private duty nursing services (PDN) are billed on a per unit basis. One unit equals one hour. Arkansas Medicaid will reimburse for the actual amount of cumulative PDN time on a monthly basis. Service time of less than one hour may not be rounded up to a full hour.
Type of service code "1" must be used when filing paper claims. Public schools must use type of service code "S" when filing paper claims for beneficiaries under age 21.
Refer to Sections 242.110 and 242.120 for PDN procedure codes for single patient care and multiple patient care.
Procedure code L8239 must be prior authorized. Form DMS-679 may be used to request prior authorization. View or print form DMS 679.
Procedure code A6549, with types of service "S" and "1", must be manually priced. Procedure code A6549 with a type of service of "1" requires a prior authorization (PA).
Refer to Section 242.130 for procedure codes of covered medical supplies.