| (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 §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 §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.
Cont'd... |
