Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-551 - Alternatives to hospital services
Subchapter II - HOME HEALTH SERVICES
Section 182-551-3300 - Private duty nursing for clients age seventeen and younger-Application requirements
Current through Register Vol. 24-18, September 15, 2024
Clients requesting private duty nursing through fee-for-service must submit a complete signed medically intensive children's program (MICP) application (DSHS form 15-398). The MICP application must include the following:
(1) DSHS 14-012 consent form;
(2) DSHS 14-151 request for DDA eligibility determination form for clients not already determined DDA eligible;
(3) DSHS 03-387 notice of practices for client medical information;
(4) Appropriate and current medical documentation including medical plan of treatment or plan of care (WAC 246-335-080 ) with the client's age, medical history, diagnoses, and the parent/guardian contact information including address and phone number;
(5) A list of current treatments or treatment records;
(6) Information about ventilator, bilevel positive airway pressure (BiPAP), or continuous positive airway pressure (CPAP) hours per day or frequency of use;
(7) History and physical from current hospital admission, recent discharge summary, or recent primary physician exam;
(8) A recent interim summary, discharge summary, or clinical summary;
(9) Recent nursing charting within the past five to seven days of hospitalization or in-home nursing documentation;
(10) Current nursing care plan that may include copies of current daily nursing notes that describe nursing care activities;
(11) An emergency medical plan that includes strategies to address loss of power and environmental disasters such as methods to maintain life-saving medical equipment supporting the client. The plan may include notification of electric and gas companies and the local fire department;
(12) A psycho-social history/summary with the following information, as available:
(13) Statement that the home care plan is safe for the child and is agreed to by the child's parent or legal guardian;
(14) Information about other family supports such as medicaid, school hours, or hours paid by a third-party insurance or trust; and
(15) For a client with third-party insurance or a managed care organization (MCO), a denial letter from the third-party insurance or MCO that states the private duty nursing will not be covered.
