NC Medicaid Private Duty Nursing for Beneficiaries Under 21 Years of Age
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Defines coverage, prior authorization, documentation, provider qualifications, and program rules for NC Medicaid Private Duty Nursing (PDN) services for beneficiaries under 21 years of age.
No material clinical or coverage changes in this revision.
Coverage Criteria and Limits
Coverage criteria (general and specific)
Covered when sections of the policy criteria are met per table of contents
Detailed criteria text appears later in the document beyond these chunks.
Medical necessity and fragility
Medical fragility and medical necessity requirements
Specific clinical thresholds are in subsequent pages.
Service limits and special situations
Amount, duration, scope and sufficiency rules
Limits and unauthorized hours discussed in section 5.3.
General coverage criteria
Covered when ALL of the following are met
References general Medicaid eligibility provisions
PDN is not covered in other settings per this section
Standard medical necessity requirement
Plan of care and physician authorization required
Licensure and employer requirements
General and Specific Coverage Criteria
Covered when ALL of the following are met:
Refers to Sections 2.0 and 3.1
Section 3.2.2
Sections 3.3.1 and 3.3.2
Short-Term Increase Criteria
Short-term increases (max 4 calendar weeks) are covered when ONE of the following is met:
Amount/duration approved by NC Medicaid PDN Nurse Consultant
General Criteria Not Covered
Medicaid shall not cover PDN when ANY of the following general conditions are true:
From Subsection 4.1
Specific Medicaid Additional Criteria Not Covered
Medicaid shall not cover PDN when ANY of the following specific conditions are true:
From Subsection 4.2.2
PDN Coverage and Modification Criteria
Coverage and modification of PDN services follow NC Medicaid approval and documented physician orders. Specific allowable situations and timeframes are described below.
Coordination of Care & Duplication
Coordination and duplication rules to prevent overlapping services and define responsibilities.
This section lists the policy’s internal table of contents entries for coverage criteria and related noncoverage sections. It indicates the presence of dedicated subsections for General Criteria Not Covered, Specific Criteria Not Covered, and Medicaid Additional Criteria Not Covered, followed by sections on Requirements for and Limitations on Coverage and Prior Approval including Prior Approval Requirements and supporting subsections.
The table of contents shows attachments and administrative subsections that support coverage criteria, including Attachment B: CMS-485 (Home Health Certification and Plan of Care), Attachment C: Physician’s Request Form for PDN, and Attachment D: PDN Prior Approval Referral Form (DMA-3061). Administrative sections referenced include Billing Units, Place of Service, Co-payments, Reimbursement, and Unit Limitations which are relevant for coverage determinations.
Attachments referenced for coverage and authorization include Attachment B: CMS-485, Attachment C: Physician’s Request Form, Attachment D: DMA-3061 (PDN Prior Approval Referral Form), Attachment E: PDN Medical Update/Beneficiary Information Form, Attachment F: Verification of Employment Form, Attachment G: Hourly Nursing Review Criteria, and Attachment H: Employment Attestation Form. These attachments are required supporting documentation for prior approval and ongoing coverage.
Definitions clarify nursing complexity: Complex care is scheduled, hands-on nursing interventions; Observation alone (without intervention) is not considered complex skilled nursing and therefore is not covered as medically necessary PDN. Substantial requires interrelated nursing assessments and interventions; tasks not requiring a licensed nurse’s assessment or judgment do not meet the substantial threshold.
The policy explicitly notes that for the subsection titled Specific Criteria Covered the entry is None Apply. Similarly, Subsection 4.2.1 Specific Criteria Not Covered by Medicaid is documented as None Apply, indicating no additional specific covered or not-covered items are listed under those headings in this excerpt.
Under Subsection 4.2.1 the document states Specific Criteria Not Covered by Medicaid: None Apply, indicating no additional, itemized Medicaid-specific exclusions are provided in that subsection of the policy text.
Coordination rules state that Home Health Nursing services must not be provided concurrently with PDN Services. The PDN provider is required to supply and bill for home health medical supplies needed by the PDN beneficiary and is expected to perform home health nursing tasks (e.g., blood draws, wound care) for that beneficiary.
The policy contains distinct sections for noncoverage and medically unnecessary scenarios (NMN). General NMN reasons include failure to meet Sections 2.0 or 3.0 eligibility/criteria, duplication of another provider’s service, or experimental/investigational services. These sections list the circumstances under which PDN would not be covered.
The policy defines Substantial nursing as requiring interrelated nursing assessments and interventions; therefore, routine tasks or interventions that do not require a licensed nurse’s assessment or clinical judgment are not considered PDN and are not covered under the substantial-care definition.
Coverage is limited to services that are individualized, specific, consistent with the beneficiary’s diagnosis or symptoms, and not in excess of the beneficiary’s needs. Services that are not individualized, exceed needs, are principally for convenience, or lack evidence-based justification do not meet the medical necessity criteria and are not covered.
The policy specifies that PDN services provided in excess of the approved amount (unauthorized hours) are not payable; such unauthorized hours are the financial responsibility of the provider agency and therefore are not covered for payment by NC Medicaid.
Claims, Codes, and Billing Rules
Prior Authorization, Documentation, and Provider Responsibilities
Prior approval required
Prior approval (PA) from NC Medicaid is required before rendering Private Duty Nursing (PDN) services; providers must submit the PA request and supporting health records to DHHS Utilization Review Personnel as described in Section 5.0.
- PA is required prior to service delivery.
- Submit prior approval request and supporting health records to DHHS Utilization Review Personnel.
Submit PA and supporting records to DHHS Utilization Review Personnel
The provider must include the prior approval request and all health records that demonstrate the beneficiary meets the specific criteria in Subsection 3.3 when submitting PA to DHHS Utilization Review Personnel.
- Include the prior approval request and all supporting clinical records demonstrating criteria in Subsection 3.3 are met.
Follow prior authorization and billing controls (Attachment A)
Attachments and administrative controls (codes, billing units, unit limitations) are listed in Attachment A and related sections; providers must follow the claims/billing guidance and unit limitations to avoid denials.
- Refer to Attachment A: Claims-Related Information for claim type, ICD-10 coding, codes, modifiers, billing units, place of service, co-payments.
- Adhere to Unit Limitations and Billing Units to avoid payment denials.
Include Physician's Request Form (DMA-3075) or physician letter
The policy references a Physician's Request Form for Private Duty Nursing (Attachment C); providers must use Attachment C (DMA-3075) or a physician-signed letter of medical necessity as part of the initial PA documentation.
- Use Attachment C (Physician's Request Form DMA-3075) or a physician-signed letter of medical necessity.
- Physician request must include diagnosis, history/date of onset, surgeries, projected discharge date, prognosis/estimated duration, and specific nursing interventions and frequency.
Attach PDN Prior Approval Referral Form (DMA-3061) and supporting forms
The PDN Prior Approval Referral Form (DMA-3061) and related attachments (CMS-485, Physician's Request Form, Medical Update form) are required documentation elements for initial PA and reauthorization; include DMA-3061 with submissions per Subsection 5.2.2.2.
- Attach PDN Prior Approval Referral Form DMA-3061 (Attachment D) to initial PA requests.
- Include CMS-485, Physician's Request (DMA-3075) or physician letter, hospital discharge summary, H&P, signed physician's order, Employment Attestation and other listed attachments.
Use Attachment D (DMA-3061) for prior approval
Attachment D is the PDN Prior Approval Referral Form (DMA-3061); providers must use this form when submitting an initial PA request or when transferring care between different agencies as specified in Section 5.2.5.2.
- Use Attachment D: PDN Prior Approval Referral Form (DMA-3061) for initial PA and transfers between different agencies.
- Include DMA-3061 when following transfer procedures in Subsection 5.2.5.2.
Prior approval required via DMA-3061 for initial review
The PDN Prior Approval Referral Form DMA-3061 is specifically required for eligibility assessment review; include DMA-3061 with the initial documentation listed in Subsection 5.2.2.2 (PDN Prior Approval Referral Form DMA-3061 is item a.).
- DMA-3061 is listed as required document a. for initial eligibility assessment review.
- Submit DMA-3061 with the other required initial documentation to NC Medicaid.
Include DMA-3061 when requesting prior approval
Attachment D (DMA-3061) is listed in the attachments and identified as the PDN Prior Approval Referral Form; providers must include this form when requesting PA for PDN services (see Attachment list and Subsection 5.2.2.2).
- DMA-3061 is Attachment D and must accompany PA submissions.
- Used for initial referral and transfer requests per policy attachments list.
Submit DMA-3061 with required supporting forms to NC Medicaid
NC Medicaid requires the PDN Prior Approval Referral Form (DMA-3061) plus supporting attachments (e.g., CMS-485, Physician's Request Form DMA-3075) for clinical review; incomplete documentation may be handled as an incomplete request and result in denial.
- Submit DMA-3061 and CMS-485, DMA-3075 or physician letter, discharge summary, H&P, signed physician's orders, Employment Attestation, and other attachments.
- Incomplete or omitted documentation may result in denial of the PA request.
DMA-3061 referenced as required PA form (Attachment D)
The PDN Prior Approval Referral Form (DMA-3061) is referenced as an attachment required for initial and transfer PA requests; include Attachment D in submissions per the attachment list.
- Attachment D: DMA-3061 is required and appears in the attachments index.
- Include DMA-3061 when assembling PA documentation.
Physician authorization required on CMS-485 for PA
Prior approval submissions must be accompanied by physician authorization: PDN services must be requested and ordered by the beneficiary's MD or DO on the CMS-485 and authorized by the beneficiary's primary physician as stated in Section 1.0 and 3.2.2.d.
- PDN must be requested and ordered by MD/DO on CMS-485 (Home Health Certification and Plan of Care).
- Services must be authorized by the beneficiary's primary physician and provided under a written individualized plan of care.
Physician authorization plus NC Medicaid prior approval required
PDN services must be authorized by the beneficiary's primary physician and provided under a written individualized plan of care; prior approval from NC Medicaid is additionally required per Section 5.0.
- Services require physician authorization and a written individualized plan of care (CMS-485).
- NC Medicaid prior approval is required even for beneficiaries under 21 (EPSDT does not waive PA).
EPSDT does not waive prior approval for under-21 beneficiaries
EPSDT does not eliminate the prior approval requirement for beneficiaries under 21; if a service requires prior approval, the beneficiary's age under 21 does NOT waive the PA requirement (see Section 2.2.1).
- Beneficiaries under 21 still require prior approval for services that otherwise require PA.
- Refer to NCTracks guidance for EPSDT and prior approval details.
Obtain prior authorization before rendering PDN services
Prior approval must be obtained before rendering PDN services; providers must submit the PA request and required supporting health records to DHHS Utilization Review Personnel and await approval per Section 5.1 and 5.2.
- Do not render PDN services without NC Medicaid PA.
- Submit PA request and required supporting records to DHHS Utilization Review Personnel.
Provisional PA: 30-day provisional approval and document deadlines
Initial provisional PA may be granted for 30 calendar days pending final documentation; CMS-485, Verification of Employment, provider consent to treat, and Verification of School Nursing (if applicable) are due by day 30 per Subsection 5.2.2.3.
- Provisional approval valid for 30 calendar days.
- Required documents (CMS-485, Verification of Employment, provider consent to treat, Verification of School Nursing) must be submitted by day 30.
Prior approval required for plan changes and agency transfers
Any request to increase or decrease the amount, scope, frequency, or duration of PDN services must be ordered by the attending physician and approved by NC Medicaid prior to implementation (Subsections 5.2.3 and 5.2.3.1).
- Physician order required for any change to amount/scope/frequency/duration.
- Obtain NC Medicaid approval prior to implementing changes.
Emergency changes — notify NC Medicaid and provide physician order within 15 business days
Emergency changes for true emergent medical necessity may be initiated outside business hours but must be reported to NC Medicaid the next business day; a documented verbal order and a physician-signed order must be provided within 15 business days (Subsection 5.2.3.3).
- Report emergency changes to NC Medicaid the next business day.
- Provide physician-signed order within 15 business days of initiating emergency care.
Follow PA change request processes and rules for temporary/emergency changes
Requests to change amount, duration, scope, and sufficiency of services (including temporary and emergency changes) must follow the processes in Section 5.2.3; temporary decreases ≤7 days do not require NC Medicaid approval but must be documented by the agency.
- Plan of care changes require NC Medicaid approval prior to implementation.
- Temporary decreases of seven days or less do not require approval but must be documented and physician notified as appropriate.
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No step therapy requirements stated
The policy contains no step therapy requirements; no step therapy rules are stated in the provided sections.
- No step therapy requirements are specified in this policy excerpt.
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No step therapy rules present
No step therapy rules or requirements are present in the cited sections of the document.
- No step therapy information in attachments or PA sections.
No step therapy requirements in these chunks
No step therapy requirements are stated in the provided policy chunks; none are specified for PDN.
- Policy does not impose step therapy for PDN.
No step therapy information present
No step therapy information is present in the cited sections; providers should follow PA and documentation rules instead.
- Follow prior authorization and documentation requirements; no step therapy applies.
Not specified
Not specified in this section of the document.
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Plan of care change and temporary change rules
Any request to increase or decrease PDN services must be ordered by the attending physician and approved by NC Medicaid prior to implementation; temporary decreases of seven days or less are allowed without prior approval and must be documented (Subsections 5.2.3, 5.2.3.1–5.2.3.2).
- Physician order and NC Medicaid approval required for permanent plan changes.
- Temporary decreases ≤7 days do not require approval but must be documented by the agency.
Transfers between agencies — submit DMA-3061, CMS-485, DMA-3075
When transferring care between two different agencies, providers must submit the PDN Prior Approval Request Form DMA-3061, the physician-signed CMS-485, and the Physician's Request Form DMA-3075 or a physician-signed letter of medical necessity (Subsection 5.2.5.2).
- Submit DMA-3061, physician-signed CMS-485, and DMA-3075 or physician letter when changing agencies.
- Follow transfer procedures in Subsection 5.2.5.2.
Maintain required documentation and contents of records
Documentation Requirements and Contents of Records are policy sections; providers must maintain required documentation for PDN services and follow the compliance and documentation sections (Section 7.2 and 7.2.1).
- Maintain documentation per Documentation Requirements and Contents of Records.
- Providers must comply with recordkeeping and verification requirements.
Follow Attachment A (Claims-Related Information) for claims
Attachment A: Claims-Related Information is referenced for claim type, ICD-10-CM/PCS, codes, modifiers, billing units, place of service and co-payments; providers must follow Attachment A guidance for claims submission.
- Refer to Attachment A for claim type, ICD-10 coding, codes, modifiers, billing units, place of service, and co-payments.
- Follow Attachment A to avoid claim submission errors.
CMS-485 (Home Health Certification and Plan of Care) required and must be uploaded regularly
A physician-signed Home Health Certification and Plan of Care Form (CMS-485) is required; the CMS-485 must document diagnoses, specific number of PDN hours per day (a range is not acceptable), frequency and interventions, and must be uploaded every 60 days during the PA period (Subsections 5.2.2.5, 248).
- CMS-485 must specify the exact number of PDN hours per day and days per week; a range is not acceptable.
- Physician-signed CMS-485 must be uploaded every 60 days during the PA period.
Include required forms: CMS-485 and Physician's Request Form
Required forms referenced include Attachment B (CMS-485) and Attachment C (Physician's Request Form) as mandatory documentation elements for PA and service provision; providers must include these forms per the attachments list.
- Include Attachment B: CMS-485 and Attachment C: Physician's Request Form with PA submissions.
- These forms are listed in the attachments index and required for review.
Submit required attachments/forms (Attachments B–H/I) with PA and reauthorization
The policy lists multiple required attachments for PA and reauthorization (Attachments B–H/I), including CMS-485, Physician's Request Form, DMA-3061, PDN Medical Update, Verification of Employment, Hourly Nursing Review Criteria, and Employment Attestation; include the applicable attachments with initial and reauthorization requests.
- Attachments include: CMS-485 (B), Physician's Request (C/DMA-3075), DMA-3061 (D), PDN Medical Update (E), Verification of Employment (F), Hourly Nursing Review Criteria (G), Employment Attestation (H), and Verification of School Nursing (I) if applicable.
- Submit required attachments with initial PA and reauthorization packets.
Use the attachments checklist when preparing PA documentation
Attachments and forms are listed across the attachment index (Attachments B–H/I); providers must assemble and submit the specific attachments required by the PA or reauthorization instructions (see Section 5.2.2.2 and 5.2.2.7).
- Assemble the applicable attachments listed in the attachment index for each submission.
- Follow the documentation checklist in Subsections 5.2.2.2 and 5.2.2.7.
Required attachments list for PA and reauthorization
Required forms and attachments for PDN PA and reauthorization include CMS-485, Physician's Request Form (DMA-3075) or physician letter, PDN Prior Approval Referral (DMA-3061), PDN Medical Update (DMA-3062), Verification of Employment (Attachment F), Hourly Nursing Review Criteria (Attachment G), and Employment Attestation (Attachment H) as specified in Subsections 5.2.2.2 and 5.2.2.7.
- Include DMA-3061, DMA-3075 (or physician letter), CMS-485, DMA-3062, Verification of Employment (F), Hourly Nursing Review Criteria (G), Employment Attestation (H) where applicable.
- Failure to include required attachments may result in incomplete request and possible denial.
Time-sensitive uploads: CMS-485 due by day 30 for provisional PA and every 60 days thereafter
The CMS-485 must be uploaded every 60 days during the PA period; during provisional approval the CMS-485, Verification of Employment, provider consent to treat, and Verification of School Nursing (if applicable) are due by day 30 (Subsections 5.2.2.3 and 5.2.2.5).
- Upload physician-signed CMS-485 every 60 days during the PA period.
- During provisional approval, submit CMS-485 and other listed documents by day 30.
Submit physician orders and discharge documentation within five business days for termination/transfers
When PDN services are terminated or reduced, the provider must submit physician orders to NC Medicaid within five (5) business days and provide discharge summaries specifying the last service date as required in Subsection 5.2.4.1 and 5.2.6.1.
- Send physician's order to terminate services to NC Medicaid within five (5) business days after discharge.
- Submit history and physical and discharge summary for transfers between health care settings.
DMA-3061 required for initial PA and transfers (Attachment D)
The PDN Prior Approval Referral Form (DMA-3061) is referenced repeatedly in the attachments and is required for PA submissions and transfers; providers must include DMA-3061 in initial and transfer PA packets (Attachment index and Subsection 5.2.5.2).
- DMA-3061 appears in the attachments index and must be used for initial PA and transfers.
- Ensure DMA-3061 is completed and attached to the PA request.
Include full documentation package for PA and reauthorization or risk denial
Initial and reauthorization PA requests must include the PDN Prior Approval Referral (DMA-3061), Physician's Request (DMA-3075) or physician letter, hospital discharge summary or recent clinical notes, most recent H&P, signed physician's order, Employment Attestation, CMS-485, Hourly Nursing Review Criteria, and other attachments listed; incomplete or omitted documentation may result in denial (Subsections 5.2.2.2 and 5.2.2.7).
- Include DMA-3061, DMA-3075 (or physician letter), hospital discharge summary/clinical notes, H&P, signed physician's order, Employment Attestation, CMS-485, Hourly Nursing Review Criteria, and other listed attachments.
- Incomplete submissions or failure to provide requested information within timeframes may result in denial.
PA requirements (including DMA-3061) apply to EPSDT cases
Attachment D (DMA-3061) and the PA process apply to EPSDT as well; beneficiaries under 21 still require prior approval and the same forms/documentation per Section 2.2.1 and Section 5.0.
- EPSDT does not eliminate PA — include DMA-3061 and required documentation for beneficiaries under 21.
- Follow NCTracks and EPSDT guidance referenced in Section 2.2.1.
Denial risk for incomplete or omitted documentation
To avoid denial, providers must submit complete documentation within specified timeframes; incomplete or omitted documentation or failure to provide requested additional information within the timeframe may result in denial of the PA request (Subsections 5.2.2.2 and 5.2.2.7).
- Complete documentation as listed in Subsections 5.2.2.2 and 5.2.2.7 must be submitted.
- NC Medicaid may treat incomplete submissions as incomplete requests and deny PA if missing information is not provided.
Do not render PDN services without PA (except provisional/emergency rules)
Prior approval is required before rendering PDN services; providers must submit the PA request and supporting records and await NC Medicaid approval per Sections 5.1 and 5.2 — do not begin services without PA except as allowed for provisional or emergency rules described in policy.
- Do not render PDN services without NC Medicaid prior approval except as allowed under provisional PA (30 days) or emergency change rules.
- Provisional PA allows limited service for 30 days pending receipt of specified documents.
Transfers between different agencies require DMA-3061, CMS-485, DMA-3075
When transferring care between different agencies, submit the PDN Prior Approval Request Form (DMA-3061), physician-signed CMS-485, and Physician's Request Form (DMA-3075) or a physician-signed letter of medical necessity as part of the transfer packet (Subsection 5.2.5.2).
- Provide DMA-3061, physician-signed CMS-485 (orders), and DMA-3075 or physician letter when transferring between different agencies.
- Follow Subsection 5.2.5.2 transfer instructions.
Assemble required attachments/forms per request type
The attachments index and documentation sections list required forms (CMS-485, Physician's Request Form, DMA-3061, PDN Medical Update, Verification of Employment, Hourly Nursing Review Criteria, Employment Attestation, Verification of School Nursing); providers must include the specific attachments required for the request type (initial PA, provisional, continuation, reauthorization, or transfer).
- Assemble and submit the attachments listed for your request type (initial, reauth, transfer).
- Refer to the attachments index to identify required forms.
School-related PDN hours require CMS-485 and Verification of School Nursing
The policy references Attachment I and other attachments for school-related documentation; for school hours the CMS-485 plus Verification of School Nursing and current school calendar are required, and CMS-485 documents allotted school hours (up to 60 hours/year) (Subsection 3.4.1 and attachments list).
- For school hours include CMS-485, Verification of School Nursing form (Attachment I), and current school calendar.
- CMS-485 may include up to 60 school-related hours per calendar year; hours above 60 require NC Medicaid approval.
Claims submission errors can cause denials — follow Attachment A guidance
Claims submitted with incorrect claim type, coding (ICD-10-CM/PCS), modifiers, billing units, place of service, or co-payments may be denied; refer to Attachment A: Claims-Related Information for claim preparation (Attachment A sections A–I) to avoid errors.
- Follow Attachment A instructions for claim type, ICD-10 coding, codes, modifiers, billing units, place of service, and co-payments.
- Claims errors can trigger denials.
Unit limitation denials and unauthorized hours financial risk
Unit limitations and billing units are documented in Attachment A and related sections; exceeding policy-specified unit limitations (unauthorized hours) will result in denials and financial responsibility rests with the provider agency (Subsection 5.3.1 and Attachment A Unit Limitations).
- Exceeding approved PDN hours (unauthorized hours) are the financial responsibility of the provider agency.
- Consult Attachment A for Unit Limitations and Billing Units guidance.
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Prior approval and documentation risk — include DMA-3061 and CMS-485
Prior approval and required documentation must be submitted; failure to provide required forms (e.g., DMA-3061, CMS-485) and clinical records may lead to denial for lack of prior approval or documentation (Subsections 5.2.2.2 and 5.2.2.7).
- Ensure DMA-3061 and CMS-485 are included in initial/reauthorization submissions.
- Incomplete submissions are handled as incomplete requests and may be denied.
Use referral and prior approval forms (DMA-3061, DMA-3075, CMS-485)
Referral and prior approval forms (DMA-3061, DMA-3075, CMS-485) are referenced and must be used for authorization decisions; include these forms per the attachments index and PA instructions.
- Use DMA-3061, DMA-3075 (or physician letter), and CMS-485 in PA packets.
- Attachments are required for clinical review and authorization.
Coverage prerequisites: private residence, physician authorization, plan of care
Coverage is limited to medically appropriate and necessary PDN in the beneficiary's private primary residence under a written individualized plan of care and authorized by the beneficiary's primary physician; services outside these prerequisites may be noncovered (Section 1.0 and 3.2.2).
- PDN is covered only in the beneficiary's private primary residence.
- Services must be under a written individualized plan of care and authorized by the primary physician.
General denial reasons — eligibility, criteria, duplication, experimental
PDN will be denied if the beneficiary does not meet eligibility in Section 2.0, does not meet criteria in Section 3.0, if the service duplicates another provider's service, or is experimental/investigational — providers must confirm eligibility and criteria before submitting PA (Section 4.1).
- Verify beneficiary meets eligibility and Section 3.0 criteria before PA submission.
- Do not request PDN for services duplicative of other providers or for experimental interventions.
Denial risk for incomplete documentation or delayed responses
Incomplete or omitted documentation or failure to provide requested additional information within specified timeframes is handled as an incomplete request and may result in denial of the PA request; providers must submit all required documents and respond to requests for additional information promptly (Subsections 5.2.2.2 and 5.2.2.7).
- Provide complete documentation as listed for initial and reauthorization reviews.
- Respond promptly to requests for additional information to avoid denial.
General noncoverage triggers — policy criteria and duplication
PDN is not covered if beneficiary does not meet policy criteria, duplicates another provider's services, or is experimental/investigational; confirm coverage criteria in Sections 2.0 and 3.0 before submitting PA (Sections 4.1 and 4.2.2).
- Confirm beneficiary meets Sections 2.0 and 3.0 criteria before requesting PDN.
- Do not request PDN where nursing tasks can be delegated to unlicensed personnel or where service is custodial/for respite.
Unauthorized hours — provider financial risk for excess services
Providing PDN services in excess of the NC Medicaid-approved amount (unauthorized hours) results in financial responsibility for the provider agency; ensure approved hours (max limits) are not exceeded (Subsection 5.3.1).
- Unauthorized hours are payable by the provider agency.
- Monitor authorized hours and obtain PA for increases.
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Use policy background and definitions to confirm PDN criteria
The policy includes a Background and Definitions section; consult Section 1.0 and definitions for clinical scope and terms when preparing PA and documentation.
- Review definitions for substantial, complex, and continuous nursing to ensure PDN criteria are met.
- Use policy definitions when preparing documentation and PA requests.
Key Definitions
Policy Background
Background: This policy governs Private Duty Nursing (PDN) for Medicaid beneficiaries under 21 years of age. It sets requirements for medical necessity, medical fragility, prior approval, documentation (including CMS-485), provider qualifications, limits on amount/frequency/duration of services, and coordination with schools and other programs.
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