CurrentAlaska MedicaidPolicy N/A

Private Duty Nursing (PDN) Service Authorization Request — Coverage Criteria

Form and instructions for requesting initial, renewal, or change (increase/decrease) in Private Duty Nursing services from Alaska Medicaid, including required clinical documentation and provider/member information. Applies to providers submitting PDN Service Authorization requests to the Alaska Medicaid Fiscal Agent.

Policy Summary

PayerAlaska Medicaid

PolicyPrivate Duty Nursing (PDN) Service Authorization Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Private Duty Nursing Service Authorization request form with required attachments and fax to the Alaska Medicaid Fiscal Agent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 formService authorization request template

15-minbilling unit increment

Faxsubmission method

Multipleclinical components

Coverage Criteria for Private Duty Nursing (PDN)

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Authorization criteria

Authorization for PDN is granted based on documentation of clinical need and completion of the SA form with required attachments. Covered when ALL of the following are met:

Form and administrative data: Completed Private Duty Nursing (PDN) Service Authorization (SA) request form indicating request type (initial, renewal, increase, decrease) and including requesting provider Alaska Medicaid ID, requesting provider NPI, organization contact information, attending physician name and NPI, member demographics, and requested procedure/service details (procedure code, specific services requested, unit/quantity, dates of service).

See form fields and instructions for required provider and service data.

Clinical documentation attached: Diagnosis code(s) and description; signed and dated physician order for PDN; Home Health Certification and Plan of Care (HCFA Form OBM 0938-0357); current nursing assessment; current medical history and/or physical or most recent hospital admission/discharge summaries; current treatment plan and treatment records; recent daily nursing notes; and emergency medical plan, as applicable.

Attach supporting documentation as indicated on the SA form.

Clinical severity and skilled nursing needs supporting hours requested: Selection of one or more clinical presentation items or skilled nursing needs that justify the frequency and total hours requested (examples include: continuous ventilator use or ventilator use ≥12 hours/day; tracheostomy management with complications or suctioning at specified frequencies; BiPAP/CPAP or oxygen management; interventions for ventilator weaning; central line care or frequent infusion therapy; enteral nutrition with complications; ADL support needed >4 hours/day; complex wound or skin care; seizure management or other nursing interventions requiring frequent monitoring).

Refer to clinical presentation and skilled nursing checklists on the form to document specific findings and frequency (e.g., assessment frequency, suctioning intervals, ventilator hours).

Unit calculation, authorization period, and billing increments: Units/quantity must be entered and are recorded as 1 unit per 15-minute increment; total units should reflect the hours requested per day and authorization period dates must be provided. The fiscal agent will record authorized/denied/modified status and provide authorization number with from/to dates.1 unit = 15-minute increment

Units entered on the SA form must match the 15-minute billing unit definition and requested dates of service.

Submission, signature, and notice of payment conditions: SA form must be signed by the professional attesting accuracy and meeting Alaska Medicaid requirements and submitted to the Alaska Medicaid Fiscal Agent (submission instructions on the form). Authorization does not guarantee payment; payment is subject to member eligibility and verification of current identification. Services are subject to post-payment review for medical necessity and completeness of documentation and may be recouped if not medically necessary or not properly documented.

See submission instructions, payment conditionality, and post-payment review statements on the form and instruction pages.

Do not use this form to request Long Term Care, Home Health, or Behavioral Health Services. This SA form is only for requests specific to Private Duty Nursing (PDN) and must indicate whether the request is an Initial, Renewal, Increase, or Decrease in units along with the requesting provider information (Alaska Medicaid ID and NPI).

Services that are not medically necessary or are not properly documented may be subject to post-payment review, and the Department of Health may recoup payment for services found to be non‑covered or non‑compliant with Medicaid/Denali KidCare program rules. Approval of an authorization request does not, by itself, guarantee payment. Providers must ensure documentation meets program requirements to avoid potential recoupment.

Provider Requirements and Submission Instructions

Prior Authorization

SA form required for authorization

A completed Private Duty Nursing Service Authorization (SA) request form is required for all initial requests, renewals, and requests to increase or decrease units. The form must include the requesting provider's Alaska Medicaid ID and NPI, organization contact information, and indicate the request type (initial, renewal, increase, or decrease).

Check appropriate box for Initial, Renewal, Increase Units, or Decrease Units
Include Requesting Provider Alaska Medicaid ID and Requesting Provider NPI
Provide organization contact name, address, phone, and fax

Billing Rule

Unit definition — 15‑minute increments

Enter units/quantity as 1 unit per 15-minute increment when documenting requested services and calculating total hours.

Record unit/qty in 15-minute billing increments (1 unit = 15 minutes)

Step Therapy

Payment conditional on member eligibility

Approval of the authorization request does not guarantee payment; payment is subject to the member's current eligibility and verification of the member identification card prior to rendering services.

Verify member eligibility and that the identification card is current before providing services

Documentation Required

Required clinical documentation — attach with SA

Attach all required clinical documentation with the SA form, including diagnosis code(s) and description, a signed and dated physician order for PDN, Home Health Certification and Plan of Care (HCFA Form OBM 0938-0357), current nursing assessment, current medical history/physical or recent discharge summaries, current treatment plan and records, recent daily nursing notes, and an emergency medical plan as applicable.

Diagnosis code(s) and description
Signed and dated physician order for Private Duty Nursing (PDN)
Home Health Certification and Plan of Care (HCFA Form OBM 0938-0357)
Current nursing assessment, medical history/physical or recent discharge summaries
Current treatment plan and records, recent daily nursing notes, emergency medical plan (as applicable)

Prior Authorization

Signature and submission — sign and fax SA

The SA request must be signed by the professional attesting that the form content is accurate and meets Alaska Medicaid program requirements, and all completed SA requests must be submitted by fax to the Alaska Medicaid Fiscal Agent at 888-772-3632.

Authorized professional must sign, print title, and date the form
Submit completed SA requests by fax to Alaska Medicaid Fiscal Agent: 888-772-3632

Denial Risk

Post-payment review and recoupment risk

Services are subject to post-payment review for medical necessity and documentation completeness; the Department may recoup payment for services that are not medically necessary, not properly documented, or not in compliance with Medicaid/Denali KidCare program rules.

Maintain complete, accurate documentation to support medical necessity to avoid recoupment

Definitions and Clinical Categories

Frequency of assessments — options and monitoring tasks

Assessment frequency optionsOnce per 8-hour shift; 2–3 times per 8-hour shift; Hourly or more often

Monitoring tasks includedVital signs, interventions to support patient care, and overall health status assessments

Behavioral/cognitive monitoring examplesNon-verbal or difficult speech, self‑abusive behavior or risk of self‑harm, sleep disturbance (awake >3 hours/night), combative/confused behavior impacting self‑management

Specified timing granularityOptions for more frequent respiratory/airway monitoring: more than once per hour; every 1–4 hours; every 4–24 hours; less frequent than every 4 hours but at least daily; less frequent than daily but at least once every 7 days

Respiratory and ventilator categories

Ventilator duration categoriesContinuous ventilator use; Ventilator use 12 or more hours/day; Ventilator use 7–12 hours/day; Ventilator use less than 7 hours/day

BiPAP/CPAP and related therapiesBiPAP/CPAP management; Nebulizer therapy; Chest physiotherapy/vest/cough assist devices

Oxygen and humidificationOxygen management; Oxygen humidification (tracheal, no ventilator); Oxygen needed at least weekly based on pulse oximetry

Suctioning and tracheostomy careTracheal suctioning at least once every 2 hours; Tracheal suctioning daily but less frequent than every 2 hours; Nasal/oral suctioning daily; Tracheostomy management with or without complications (e.g., skin breakdown, replacement needed)

Weaning and standby statusesInterventions in place for active weaning; Ventilator weaning achieved requiring ongoing monitoring/management; Ventilator on standby or used at night for <1 hour

OpenPayer

Private Duty Nursing (PDN) Service Authorization Request — Coverage Criteria

Coverage Criteria for Private Duty Nursing (PDN)

Billing and Unit Definitions

Provider Requirements and Submission Instructions

Background and Scope

Definitions and Clinical Categories