23 Miss. Code. R. 223-4.4

Current through December 10, 2024

Rule 23-223-4.4 - Prior Authorization and Concurrent Reviews

A. Private duty nursing (PDN) providers must submit a prior authorization request to the Division of Medicaid or designee prior to the initiation of PDN services which must include, at a minimum, the following:

1. A signed physician or specialist's order for PDN and a signed initial Plan of Care (POC),

2. Beneficiary diagnosis(es),

3. Skilled teaching/instructions to be provided to a family member or caregiver(s),

4. Treatment plan/physician orders specifying each skill to be performed including whether the service(s) require a registered nurse (RN) or a licensed practical nurse (LPN),

5. Expected duration of service,

6. Identification of any other home care services, including the hours, days, and times of these services being provided, including, but limited to:

a) Case management,

b) Physical therapy,

c) Speech therapy,

d) Occupational therapy,

e) Respiratory therapy,

f) Respite,

g) Hospice, and/or

h) Personal care attendant.

7. When PDN medical necessity criteria are no longer met, a plan:

a) For reducing and discontinuing PDN hours, and

b) To transition the beneficiary to the most appropriate setting.

B. The PDN provider must submit a recertification of PDN services, every six (6) months indicating the number of hours per day or week and the duration of the request to the Division of Medicaid, or designee and include the following:

1. An updated POC,

2. Progress notes,

3. Monthly summaries, and

4. Nursing visit notes.

C. The PDN provider cannot bill the beneficiary for hours when the provider failed to seek certification/recertification in a timely manner.

23 Miss. Code. R. 223-4.4

42 C.F.R. § 440.80; Miss. Code Ann. §§ 43-13-117, 43-13-12.

Adopted 4/1/2020

Amended 6/1/2020

Amended 7/1/2020