Current through all regulations passed and filed through September 16, 2024
(A) As a
prerequisite to receiving private duty nursing (PDN) services, an individual
must meet the requirements set forth in rule
5160-12-02 of the Administrative
Code, as applicable, which require the individual to receive PDN authorization
from the Ohio department of medicaid (ODM) or its designee.
(B) The procedures set forth in this
paragraph must be followed when securing a PDN authorization for
individuals who are not enrolled on a home and
community-based services (HCBS) waiver.
(1)
The PDN provider shall submit a referral for PDN authorization to ODM using the
ODM 02374, "Private Duty Nursing (PDN) Services Request" (3/2015), along with
any additional supporting documentation requested by ODM.
(2) ODM shall conduct an in-person assessment
and/or perform a desk review to determine if, in accordance with rule
5160-12-02 of the Administrative
Code, the individual has a medical condition that meets the criteria for an
comparable institutional level of care, including a nursing facility-based
level of care, and the services are medically necessary as set forth in rule
5160-1-01 of the Administrative
Code.
(a) If ODM determines the individual
has a medical condition that meets the criteria for a nursing facility-based
level of care, and PDN services are medically necessary as set forth in rule
5160-1-01 of the Administrative
Code, ODM shall:
(i) Notify the PDN provider
in writing of the authorized amount, scope and duration of PDN services and the
PDN authorization number. The PDN provider shall begin furnishing PDN services
to the individual upon receipt of written PDN authorization and in accordance
with all other requirements set forth in rule
5160-12-02 of the Administrative
Code.
(ii) Inform the individual of
the PDN authorization, specifying the authorized amount, scope and duration of
PDN services.
(b)
If the individual disagrees with the authorized amount,
scope and/or duration of PDN services, the individual may request a hearing in
accordance with division 5101:6 of the Administrative Code.
(c)
If ODM determines the individual does not have a medical condition that meets
the criteria for an institutional level of care, including a nursing
facility-based level of care, and/or the services are not medically necessary
as set forth in rule
5160-1-01 of the Administrative
Code, ODM:
(i) May conduct an additional
review of the PDN authorization request that has been proposed for denial,
and/or
(ii) Shall deny the PDN
authorization request, and issue a denial notice and hearing rights to the
individual in accordance with division 5101:6 of the Administrative Code,
and
(iii) Shall notify the PDN
provider in writing of the denial of the PDN authorization request.
(3) The provider shall
notify ODM in writing using the ODM 02374 when there is any change in the
individual's condition that the provider believes may warrant a change in the
amount, scope or duration of PDN services.
(C) The procedures set forth in this
paragraph must be followed when securing a PDN authorization for
individuals enrolled on an HCBS waiver administered by
the Ohio department of aging (ODA) if applicable for an
adult. The period for which PDN authorization applies shall not exceed three
hundred sixty-five days.
(1) The individual,
or PDN provider shall request that the ODA case manager if applicable, submit a referral for PDN
authorization to ODM using the ODM 02374 along with any additional supporting
documentation requested by ODM. The case manager shall assist the individual in
securing a potential PDN service provider.
(2) ODM shall conduct an in-person assessment
and/or perform a desk review to determine if, in accordance with rule
5160-12-02 of the Administrative
Code, the individual is enrolled on an ODA administered waiver as
applicable for an adult, and has a medical condition that requires PDN services
that are medically necessary in accordance with rule
5160-1-01 of the Administrative
Code.
(a) If ODM determines, in accordance
with rule
5160-12-02 of the Administrative
Code, the individual is enrolled on
an ODA administered waiver, and has a
medical condition that requires PDN services that are medically necessary in
accordance with rule
5160-1-01 of the Administrative
Code, ODM shall:
(i) Notify the
ODA case manager, as applicable, in
writing of the authorized amount, scope and duration of PDN services and the
PDN authorization number. The ODA
case manager shall notify the PDN provider of the authorized amount, scope and
duration of PDN services and the PDN authorization number. The PDN provider
shall begin furnishing PDN services to the individual upon receipt of written
PDN authorization and in accordance with all other requirements set forth in
rule 5160-12-02 of the Administrative
Code.
(ii) Inform the individual of
PDN authorization specifying the authorized amount, scope and duration of PDN
services.
(b) If the
individual disagrees with the authorized amount, scope and/or duration of PDN
services, the individual may request a hearing in accordance with division
5101:6 of the Administrative Code.
(c) If ODM cannot confirm, in accordance with
rule 5160-12-02 of the Administrative
Code, the individual is enrolled on
an ODA administered waiver, and/or
cannot confirm that the individual has a medical condition that requires PDN
services that are medically necessary in accordance with rule
5160-1-01 of the Administrative
Code, ODM shall:
(i) Deny the PDN
authorization request and issue a denial notice and hearing rights to the
individual in accordance with division 5101:6 of the Administrative
Code.
(ii) Notify the
ODA case manager in writing of the
denial of the PDN authorization request. The ODA case manager shall notify the PDN provider in writing of the
denial.
(3)
The provider shall notify ODM and the ODA case manager in writing using the ODM 02374 when there is any
change in the individual's condition that the provider believes may warrant a
change in the amount, scope or duration of PDN services.
(4) The ODA case manager shall notify ODM in writing using the ODM 02374
when there is a change in the individual's level of care.
(D)
The procedures
set forth in this paragraph must be followed when obtaining PDN approval for an
individual enrolled on a HCBS waiver administered by the Ohio department of
developmental disabilities (DODD). The period for which PDN approval applies
shall not exceed three hundred sixty-five days.
(1)
The individual,
or PDN provider shall request that the county board services and support
administrator (SSA) submit a referral for PDN services to the designee at DODD
along with any additional supporting documentation requested by DODD. The
county board SSA shall assist the individual in securing a potential PDN
service provider.
(2)
DODD shall determine if, in accordance with rule
5160-12-02 of the Administrative
Code, the individual has a medical condition that requires PDN services which
are medically necessary, as set forth in rule
5160-1-01 of the Administrative
Code.
(a)
If
DODD determines the individual has a medical condition that requires PDN
services which are medically necessary, DODD shall notify the county board SSA
in writing of the authorized amount, scope and duration of PDN services.
(i)
County board SSA
shall notify the PDN provider of the authorized amount, scope and duration of
PDN services. The PDN provider shall begin furnishing PDN services to the
individual upon receipt of written PDN approval and in accordance with all
other requirements set forth in rule
5160-12-02 of the Administrative
Code.
(ii)
County board SSA shall inform the individual of PDN
authorization specifying the authorized amount, scope and duration of PDN
services.
(b)
If the individual disagrees with the authorized amount,
scope and/or duration of PDN services, the individual may request a hearing in
accordance with division 5101:6 of the Administrative Code.
(c)
If DODD
determines the individual does not have a medical condition that requires PDN
services and/or the services are not medically necessary as set forth in rule
5160-1-01 of the Administrative
Code, DODD:
(i)
Shall deny the PDN service request, and issue a denial
notice and hearing rights to the individual in accordance with division 5101:6
of the Administrative Code, and
(ii)
Shall notify the
county board SSA and the PDN provider of the denial of the PDN authorization
request.
(E) PDN services shall
be approved for individuals enrolled on an ODM administered HCBS waiver as a
result of the in-person assessment or reassessment conducted by ODM or its
designee in accordance with rule
5160-46-02 of the Administrative
Code, or the reassessment conducted in accordance with rule
5160-50-02 of the Administrative
Code. As set forth in rule
5160-12-02 of the Administrative
Code, PDN services must be medically necessary in accordance with rule
5160-1-01 of the Administrative
Code.
(1) The case manager shall assist the
individual in securing a PDN service provider.
(2) If PDN services are approved, ODM or its
designee shall:
(a) Record the amount, scope
and duration of approved PDN services on the all services plan.
(b) Notify the provider, in writing, of the
amount, scope and duration of approved PDN services.
(c) Inform the individual of PDN service
approval in writing after conducting the assessment or reassessment, and
provide a written notice to the individual specifying the approved amount,
scope and duration of PDN services.
(3) If the individual disagrees with the
authorized amount, scope and/or duration of PDN services, the individual may
request a hearing in accordance with division 5101:6 of the Administrative
Code.
(4) If PDN services are
denied, ODM or its designee shall issue a denial notice and hearing rights to
the individual in accordance with division 5101:6 of the Administrative
Code.
(5) Requests for a change in
the amount, scope and/or duration of authorized PDN services shall be submitted
to ODM or its designee. ODM or its designee shall conduct an in-person
reassessment and/or perform a desk review to evaluate the request.
(F) Additional PDN services beyond what ODM or its
designee has authorized may be provided to an individual in an emergency when
the provider has an existing PDN authorization to provide PDN services to that
individual. For the purposes of this rule, emergency services are provided
outside of normal state of Ohio office hours when prior authorization cannot be
obtained.
(1) PDN services may be delivered
in an emergency and a new PDN authorization obtained after the delivery of
services. The PDN services must be medically necessary in accordance with rule
5160-1-01 of the Administrative
Code, and the services must be necessary to protect the health and welfare of
the individual.
(2) The provider
shall notify ODM, or the ODA case
manager, as applicable, in writing using the ODM 02374,
or the county board SSA for individuals enrolled on a DODD administered
waiver when emergency PDN services are delivered. Notification shall be
immediate, or no later than the first business day following the emergency
provision of PDN services.
(G) The provider shall
maintain all written records related to the provision of PDN service and its
authorization for a period of six years following receipt of the request or
until an initiated audit is resolved, whichever is longer.
