Current through Reg. 49, No. 38; September 20, 2024
(a) PDN services must be prior authorized.
Prior authorization is a condition of reimbursement but is not a guarantee of
payment.
(b) HHSC will publish in
the Texas Medicaid Provider Procedures Manual and websites all
processes, tools, and scales used to prior authorize PDN services. HHSC may use
only these processes, tools, and scales to prior authorize PDN
services.
(c) The provider must
submit a complete request for prior authorization in order to be considered by
HHSC for reimbursement. The authorization request must include the
authorization form approved by HHSC, signed and dated by the recipient's
treating physician. The provider must use the documents, tools, or processes
published in the Texas Medicaid Provider Procedures Manual or
any updates made available through bulletins, banners, or other means to
request prior authorization.
(d)
Documentation supporting the prior authorization request must clearly and
consistently describe the recipient's:
(1)
current diagnosis;
(2) functional
status and condition;
(3) history
and treatment; and
(4) frequency
and complexity of skilled nursing needs, as those needs arise over the span of
a 24-hour day.
(e) The
supporting documentation:
(1) must include:
(A) documentation of the treating physician's
orders, e.g., a prescription or a written or documented verbal order signed and
dated by a treating physician; and
(B) a plan of care that satisfies the
requirements as described in §
RSA 363.313 of this
subchapter (relating to Plan of Care);
(2) may include any additional materials the
provider may choose to submit that supports the medical necessity of the
requested PDN services;
(3) must
explain to HHSC's satisfaction how the requested PDN is necessary to correct or
ameliorate the recipient's disability or physical or mental illness or
condition; and
(4) must show that
the recipient's skilled nursing needs cannot be met on a part-time or
intermittent basis by a visiting nurse as described in Chapter 354, Subchapter
A, Division 3 of this title (relating to Medicaid Home Health
Services).
(f) Process
for authorizations.
(1) HHSC authorizes
requested PDN services required to meet all of the recipient's PDN needs when
the medical necessity for a private duty nurse is documented.
(2) HHSC reviews requests for PDN services
that comply with subsections (b) through (e) of this section.
(3) The information must be complete and
consistent throughout the documentation associated with the prior authorization
request for PDN services.
(4) PDN
services are prior authorized with reasonable promptness. Prior authorization
determinations are completed by HHSC within three business days of receipt of a
complete request.
(5) If a request
for PDN is incomplete, inconsistent, or unclear, HHSC, its contractor, or MCO
will contact the provider to request additional or clarifying documentation to
enable HHSC to make a decision on the request.
(6) Prior authorizations for PDN services are
not denied or reduced based solely on the recipient's diagnosis, type of
illness, or health condition.
(7)
Prior authorizations for PDN services are not denied or reduced solely because
the recipient's condition or health status is stable or has not
changed.
(g) HHSC
authorizes requested medically necessary PDN services when:
(1) the prior authorization request for PDN
is complete, as described in subsections (b) through (e) of this
section;
(2) the requested services
are nursing services as defined by the Texas Nursing Practice Act and its
implementing regulations; and
(3)
no third-party resource, as described in the Texas Medicaid Provider
Procedures Manual, is financially responsible for the requested
services.
(h) HHSC may
deny or reduce PDN services when the:
(1)
request is incomplete;
(2)
information in the request is inconsistent;
(3) documentation does not explain to HHSC's
satisfaction the medical need for a private duty nurse or no longer supports
the medical need for a private duty nurse;
(4) documentation does not address how PDN
services correct or ameliorate the recipient's disability or physical or mental
illness or condition;
(5) requested
PDN services are not nursing services as defined by the Texas Nursing Practice
Act and its implementing regulations;
(6) medical director, after conferring with
the recipient's treating physician, determines the requested PDN services are
not medically necessary to correct or ameliorate the recipient's disability or
physical or mental illness or condition; or
(7) recipient's nursing needs could be met
through a visiting nurse as described in Chapter 354, Subchapter A, Division 3
of this title.
(i) Only
the medical director may deny PDN services on the basis that the services do
not correct or ameliorate the recipient's disability or physical or mental
illness or condition. Before denying PDN services, the medical director will
contact the recipient's treating physician to determine whether additional
information or clarification can be provided that would allow for authorization
of PDN services.
(j) All notices
must afford a recipient an opportunity for a fair hearing in accordance with 42
CFR, Part 431, Subpart E, related to Fair Hearings for Applicants and
Recipients.
(1) HHSC may determine, based on
the information submitted, that PDN services will be denied, terminated, or
reduced. A notice regarding the denial, termination, or reduction of PDN
services must be sent to the recipient and the requesting provider. The notice
must inform the recipient of his or her right to request a fair hearing as
described in Chapter 357, Subchapter A of this title (relating to Uniform Fair
Hearing Rules).
(2) When HHSC
determines that the requested services are not PDN services and that the
documentation may support authorization of personal care services, as described
in Subchapter F of this chapter (relating to Personal Care Services), the
denial notice:
(A) describes the basis for
this determination;
(B) briefly
describes the personal care services benefit; and
(C) explains how to request personal care
services.
(3) When HHSC
determines that documentation for the services requested does not support a
request for PDN because the recipient does not need more individual and
continuous nursing care than could be provided on a per-visit basis, as
described in §
RSA 354.1031 of this
title (relating to General), the denial notice:
(A) describes the basis for this
determination;
(B) briefly
describes the home health nursing benefit; and
(C) explains how to request prior
authorization for home health nursing.
(4) When HHSC determines that the request for
PDN services is incomplete, as referenced in subsection (h)(1) of this section,
the denial notice will inform the recipient that the documentation or
information is incomplete and identify the sections of the documentation or
information that are incomplete.
(5) When HHSC determines that the request for
PDN services is inconsistent, as referenced in subsection (h)(2) of this
section, the denial notice will inform the recipient that the documentation or
information is inconsistent and identify the inconsistencies.
(6) When HHSC determines that the request for
PDN services does not explain to HHSC's satisfaction the medical need for a
private duty nurse or no longer supports the medical need for a private duty
nurse as referenced in subsection (h)(3) of this section, the denial notice
will inform the recipient and address how the documentation or information does
not explain to HHSC's satisfaction the medical need for a private duty nurse or
how the documentation no longer supports the medical need for a private duty
nurse.
(7) When HHSC determines
that the information provided does not address how PDN services correct or
ameliorate the recipient's disability or physical or mental illness or
condition as referenced in subsection (h)(4) of this section, the denial notice
will inform the recipient and address how the information provided in the
request does not support the medical need for PDN services.
(8) When HHSC determines that the requested
PDN services are not nursing services as defined by the Texas Nursing Practice
Act and its implementing regulations, as referenced in subsection (h)(5) of
this section, the denial notice will inform the recipient and address how the
requested PDN services are not nursing services as defined by the Texas Nursing
Practice Act and its implementing regulations.
(9) When an HHSC medical director, after
conferring with the recipient's treating physician, determines the requested
PDN services are not medically necessary to correct or ameliorate the
recipient's disability or physical or mental illness or condition, as
referenced in subsection (h)(6) of this section, the denial notice will inform
the recipient and address why the requested PDN services are not medically
necessary to correct or ameliorate the recipient's disability or physical or
mental illness or condition.
(10)
When HHSC determines that the recipient's nursing needs could be provided by a
visiting nurse through Home Health Skilled Nursing services, as referenced in
subsection (h)(7) of this section, the denial notice for PDN services will
describe the basis for the denial and explain how to request Home Health
Skilled Nursing services.
(k) A provider's authorization for PDN
services is terminated if the recipient is no longer eligible for
EPSDT.
(l) HHSC may ask a provider
to take on an existing authorization for PDN services if it becomes necessary
to terminate another provider's authorization for PDN services because the:
(1) recipient's health and safety needs are
in jeopardy; or
(2) PDN services
provided are inconsistent with the plan of care submitted for
authorization.
