016.06.06 Ark. Code R. 067

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.06-067 - Private Duty Nursing (PDN) Provider Manual Update Transmittal #71

SUBJECT: Provider Manual Update Transmittal #71

REMOVE	INSERT
Section	Date	Section	Date
213.000	7-1-06	213.000
225.000	7-1-06	225.000

Explanation of Updates

Sections 213.000 and 225.000 are included to clarify that a primary care physician (PCP) Child Health Services (EPSDT) screening/ referral is required to receive private duty nursing services.

Paper versions of this update transmittal have updated pages attached to file in your provider manual. See Section I for instructions on updating the paper version of the manual. For electronic versions, these changes will be automatically incorporated.

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 682-6789 (TDD only).

If you have questions regarding this transmittal, please contact the EDS Provider Assistance Center at 1-800-457 -4454 (Toll-Free) within Arkansas or locally and Out-of-State at (501) 376-2211.

Arkansas Medicaid provider manuals (including update transmittals), official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Thank you for your participation in the Arkansas Medicaid Program.

213.000Coverage of Private Duty Nursing Services for Medicaid-Eligible Beneficiaries Under 21

Private Duty Nursing Services (PDN) may be covered for Medicaid beneficiaries under 21 who meet the following requirements:

A. Medicaid-eligible beneficiaries under age 21 who are:

1.I n the Child Health Services (EPSDT) Program, and

2. High technology non-ventilator dependent beneficiary requiring at least two (2) of the following services, unless the beneficiary requires an extremely high level of one (1) service making a home care plan impossible without private duty nursing services:

a. Intravenous Drugs (e.g. chemotherapy, pain relief, or prolonged IV antibiotics)

b. Respiratory - Tracheostomy or Oxygen Supplementation

c. Total Care Support for ADLs and close patient monitoring

d. Hyperalimentation - parenteral or enteral

PDN services may be provided by a registered nurse and/or licensed practical nurse as directed by the beneficiary's physician.

Medicaid-eligible beneficiaries under age 21 who are in the Child Health Services (EPSDT) program require additional documentation to receive private duty nursing services. Refer to section 225.000 of this manual.

All PDN services require prior authorization by the Medicaid Program. Refer to section 220.000 of this manual for information on the prior authorization process.

225.000Filing for Prior Authorization

To request prior authorization, the Private Duty Nursing Services (PDN) provider must complete and forward the original and one copy of Form DMS-2692 to the Division of Medical Services Utilization Review Section. View or print the DMS Utilization Review Section contact information.

A copy of the form should be retained in the provider's records.

Additional documentation is required for PDN services for eligible Medicaid beneficiaries under age 21. The following documentation must be provided:

A. Current medical and surgical history

B. Current psychosocial assessment

C. Current PDN care plan (Home Health Certification and Plan of Care - form CMS-485)

View or print form CMS-485.

D. A referral from the current primary care physician (PCP) must be on file in the beneficiary's record. This referral must be the result of the Child Health Services (EPSDT) screen. This requirement may be waived only for the request of a hospitalized child.

1. This screening/referral must document all age appropriate Child Health Services (EPSDT) medical screening components. (Refer to the Child Health Services (EPSDT) provider manual section 215.200)

New requests for PDN services should be sent to the Division of Medical Services, Utilization Review Section (UR) as early as possible after the medical need for private duty nursing is identified.

Providers must submit requests for prior authorization of PDN services within 30 days of the beginning date of service. Providers assume the risk of services ultimately being found not medically necessary. When PDN services are approved by UR at the level requested, the effective date of the prior authorization will be retroactive to the beginning date of service.

016.06.06 Ark. Code R. 067

10/6/2006