New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-W - Former Division of Human Services
Chapter He-W 500 - MEDICAL ASSISTANCE
Part He-W 540 - PRIVATE DUTY NURSING SERVICES
Section He-W 540.07 - Prior Authorization and Review

Universal Citation: NH Admin Rules He-W 540.07

Current through Register No. 40, October 3, 2024

(a) All requests for PDN shall require written prior authorization from the department or its prior authorization agent before the recipient receives PDN.

(b) The PDN service provider shall submit a prior authorization request to the department or its prior authorization agent, along with sufficient current medical and psychosocial information to enable the department or its prior authorization agent to evaluate the request and make a determination.

(c) The information required by (b) above shall include, but not be limited to:

(1) A written, signed, and dated physician's or other licensed practitioner's order, as described in He-W 540.06(a);

(2) The nursing assessment, as described in He-W 540.06(b); and

(3) The plan of care, as described in He-W 540.06(c).

(d) If further medical information is necessary, the department or its prior authorization agent shall contact the recipient's physician, other licensed practitioner, or PDN service provider directly by letter, fax, or telephone and request the additional information.

(e) The department or its prior authorization agent shall determine if PDN is appropriate, and if so, the number of hours authorized and the start and end date of the PDN authorization period, based on an evaluation of the following clinical information provided or gathered in accordance with (b)-(d) above:

(1) The order and direction of the recipient's physician or other licensed practitioner;

(2) The frequency of the recipient's need for skilled nursing observation, judgment, assessment, or interventions;

(3) The nursing assessment;

(4) The identified problems and goals in the plan of care; and

(5) For authorization extensions in (o) below, as applicable, the assessment of needs based on the face-to-face nursing visit in (k) and (l) below.

(f) The term of prior authorized services shall be valid for no less than 6 months, unless a shorter term is identified by the practitioner ordering the PDN services, from the start date and may be longer based on the clinical prognosis of the recipient,

(g) Requests for prior authorization shall be denied by the department or its prior authorization agent if, based on the evaluation in (e) above:

(1) Any of the requirements in He-W 540 are not met, including eligibility requirements in He-W 540.02, coverage requirements in He-W 540.04 and 540.05, documentation requirements in He-W 540.06, or prior authorization requirements in He-W 540.07; or

(2) It is determined that:
a. The recipient does not require skilled nursing services;

b. The recipient does not require continual skilled nursing observation, judgment, assessment, or interventions for more than a 2 hour duration; or

c. There are less costly and equally effective alternatives available, such as care provided by alternative providers including personal care attendants, licensed nursing assistants, or homemakers, which will provide the recipient with the same level of service.

(h) If a request for prior authorization is denied by the department or its prior authorization agent, notice of denial shall be forwarded to the recipient, to include:

(1) The reason for, and legal basis of, the denial; and

(2) Information that an administrative appeal on the denial may be requested within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200.

(i) If an initial request for authorization is approved, the department or its prior authorization agent shall issue a temporary initial authorization for a 90-day period.

(j) Notice of the initial authorization in (h) above shall be sent to the recipient and the PDN service provider and include a face-to-face or virtual nursing visit between the department, or its designated party, and the recipient shall be completed within a 90-day period

(k) If the department or its prior authorization agent approves the prior authorization request, then the PDN service provider shall receive notification, which confirms the approval, includes the number of hours authorized and, documents the start and end date of the PDN authorization period.

(l) Within the 90 days in (i) above, and at least once annually for all approved authorization requests, the department or its designated party shall conduct a face-to-face or virtual nursing visit with the recipient in order to:

(1) Assess the recipient's needs;

(2) Identify other supports in the home;

(3) Verify the clinical appropriateness of the initial authorization or subsequent authorization extensions made based on the clinical evaluation in (e) above; and

(4) Provide education to the recipient.

(m) The face-to-face nursing visit may be conducted in person virtually by electronic means.

(n) The requirements of (i) through (m) above shall not apply to recipients being discharged from any of the locations listed in He-W 540.05(a) when the department has participated in the recipient's discharge planning, except that the requirements for an annual nursing visit as described in (l) above shall still apply.

(o) The department shall review subsequent authorization requests within 90 days for continued approval.

(p) If the face-to-face or virtual nursing visit confirms the initial authorization was clinically appropriate, the department or its prior authorization agent shall issue notification which confirms the approval, includes the number of hours authorized, and documents the start and end date of the PDN authorization period.

(q) For PDN to extend beyond the authorized duration, the PDN service provider shall request and obtain prior authorization in accordance with this section.

(See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff 4-17-12, EXPIRES: 10-15-12; ss by #10186, eff 10-15-12

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