Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.09-008 - Private Duty Nusing Services Update #104

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.

Prior authorization is required for private duty nursing supervisory visits. The Prior Authorization request must be submitted with the monthly service billing along with supporting documentation. 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.

The following procedure codes are applicable when billing the Arkansas Medicaid Program for private duty nursing services.

*Effective for dates of service on and after April 4, 2008 procedure code S9123 U1 can be billed for a RN supervisory visit. The maximum time allowed for reimbursement per visit is 3 hours, with a maximum of 18 visits per state fiscal year. Supervisory visits (as defined by the Arkansas Department of Health Rules and Regulations for Home Health Agencies) must be face-to-face and provided in a setting approved for private duty nursing services (see section 242.200). Beneficiaries receiving extended care will require no less frequency than every two weeks of supervision. For beneficiaries classified as stable or chronic (beyond the first 3 months of extended care), RN supervisory visits will be no less than every 30 days.

When a private duty nurse is caring for two patients simultaneously in the same location, the following procedure codes are to be used for the care provided to the second patient:

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 will not be rounded up to a full hour. Attach supervisory visit billing information with supporting documentation and assessment with the monthly private duty nursing billing. No supervisory visits will be covered without first providing prior authorized private duty nursing services within the same month. Billing units are cumulative up to one hour for the duration of one month. Supervisory visits of less than an hour can be billed cumulatively on a monthly basis but any visit less than a unit (hour) cannot be rounded up. Providers must file separate claims indicating the number of hours for each patient.

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.