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Provider Notice: Private Duty Nursing (PDN) Authorization process

April 12, 2018

PROVIDER NOTICE

Community First Health Plans will implement the following revisions to our Private Duty Nursing (PDN) Authorization process for STAR Medicaid, STAR Kids and CHIP effective May 12, 2018.

Applicable Programs:

  • All requests for PDN services require review and authorization for STAR, STAR Kids and CHIP members.

Initial Requests for PDN require the following:

  • Authorization Review Process - All initial Private Duty Nursing requests will be submitted to a CFHP Medical Director for review as part of CFHP’s Medical Director Review (MDR) process. Those initial PDN requests meeting approval criteria will be approved for a maximum of three (3) months.
  • Additional Documentation – A PDN provider may be asked to submit additional documentation including, but not limited to, nurse's notes and specialist notes addressing such items as: medication administration records, seizure logs, and ventilator logs to support medical necessity as defined in the Texas Medicaid Provider Procedures Manual.
  • Special Provision for Verbal Orders - If PDN services begin as a result of a verbal order before the Practitioner’s dated signature, proof of the verbal order must be submitted with the request. Example: A PDN agency submitted a Member’s hospital discharge plan indicating that PDN is needed due to a Member’s new complex condition. The Medical Director Review (MDR) process is required on all verbal order requests.

Reauthorization Requests:

  • Authorization Review Process - All reauthorization requests for PDN must be submitted to CFHP for review.
  • Provision of Nursing Notes - Providers must submit the most recent two (2) weeks of Nursing Notes.
  • Additional Documentation – Providers MAY BE asked to submit additional documentation including, but not limited to, nurse's notes greater than the most recent two (2) weeks of notes and specialist provider notes addressing such items as: medication administration records, seizure logs, and ventilator logs to support medical necessity as defined in the Texas Medicaid Provider Procedures Manual.

If you have any questions, please call us at 210-358-6030, choose option 2 then option 5.

We will be happy to help.