ModifiedAlliance HealthPolicy 3G-1

Private Duty Nursing (PDN) for Beneficiaries Age 21 and Older

Governs coverage, eligibility, definitions, and requirements for Private Duty Nursing services for NC Medicaid beneficiaries age 21+, including settings, provider qualifications, authorized hours, and documentation/PA processes.

Policy Summary

PayerAlliance Health

PolicyPrivate Duty Nursing (PDN) for Beneficiaries Age 21 and Older

Policy CodePolicy 3G-1

Change TypeAmendment (May 15, 2024)

Effective Date

Next Review Date

Key ActionSubmit required prior approval forms (e.g., DMA-3508/DMA-3511, CMS-485) and supporting documentation before initiating PDN or short-term increases.

SourceLink

POLICY UPDATE CHANGES

Amended Date: May 15, 2024 with multiple content updates including caregiver allowances and policy language updates.

Policy language defining PDN and medical necessity was replaced and updated (02/15/2024).

Allowance for near relatives or legally responsible persons to deliver PDN if they are licensed and operate within scope; replaced previous blanket prohibitions.

21+Age governed

Private residencePlace of service

112/wkProgram max hours

56–112/wk

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Standard Level 1 range

180 daysPA period length

Coverage Criteria for PDN

inv-01: General Criteria Covered

Covered when ALL of the following are met:

PDN coverage prerequisites: (1) PDN is medically appropriate and medically necessary for the beneficiary; (2) Services are provided only in the beneficiary's private primary residence; (3) Services are under the direction of a written individualized plan of care; (4) Authorized by the beneficiary's primary physician; (5) Rendered by a registered nurse (RN) or licensed practical nurse (LPN) licensed by the North Carolina Board of Nursing and employed by a state licensed and accredited home care agency; (6) PDN is supplemental to care provided by family, foster parents, or delegated caregivers.

Derived from Sections 1.0 and 1.1.1

inv-02: General Coverage Criteria

Covered when ALL of the following are met

General coverage: a) The service is individualized, specific, and consistent with symptoms or a confirmed diagnosis and not in excess of the beneficiary's needs; b) The service can be safely furnished and no equally effective, more conservative, or less costly statewide option exists; c) The service is not primarily for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

From Section 3.1 General Criteria Covered

inv-03: Medicaid Additional Criteria Covered (PDN eligibility)

Covered when ALL of the following are met

PDN Additional Criteria: a) Eligibility criteria in Section 2.0 are met; b) Health criteria in Section 3.3 are met; c) Services are provided primarily in the beneficiary's private primary residence to prevent institutionalization, with limited allowance for normal life activities outside the residence; d) PDN is ordered by the attending MD/DO on the CMS-485 (Home Health Certification and Plan of Care Form); e) Prior approval has been granted by NC Medicaid per Section 5.0; f) The beneficiary has at least one trained primary informal caregiver available (PDN not approved without caregiver).

From Section 3.2.2

inv-04: PDN Level 1 Services Criteria

Eligible for Level 1 when ONE of the following OR at least four of the listed criteria are met

Level 1 - ventilator dependence: Dependent on a ventilator for at least eight (8) hours per day.>= 8 hours/day ventilator dependence

Section 3.3.1 (a)

Level 1 - alternate criteria (meet at least four): Meet at least four of the following: unable to wean from a tracheostomy; require nebulizer treatments at least two scheduled times per day plus one PRN per day; require pulse oximetry readings every nursing shift; require skilled nursing or respiratory assessments every shift due to respiratory insufficiency; require oxygen PRN or PRN rate adjustments at least two times per week; require tracheal care at least daily; require PRN tracheal suctioning (suction machine and flexible catheter required); at risk for requiring ventilator support; require at least one non-respiratory skilled nursing intervention requiring more extensive continuous care than a home health visit; evidence of three or more significant organ system deficiencies/failures requiring regular skilled interventions to avoid decompensation.meet >=4 items

Section 3.3.1 (b) items 1–10

inv-05: PDN Level 2 Services Criteria

Eligible for Level 2 when ALL Level 1 criteria are met AND at least one Level 2 criterion is met

Level 2 eligibility: Meets ALL Level 1 nursing services criteria AND at least one of the following: use of a respiratory pacer; dementia or other cognitive deficits in an otherwise alert or ambulatory recipient; infusions such as via IV, PICC, or central line; seizure activity requiring PRN Diastat, oxygen, or other interventions that require assessment and intervention by a licensed nurse.

Section 3.3.2; Level 2 may allow additional hours up to the program limit.

inv-06: Amount/Duration/Scope Determination and Approved Hours

Approved hours are determined based on comprehensive review and beneficiary characteristics

Hours determination: NC Medicaid determines amount, duration, scope, and sufficiency of PDN services (not to exceed 112 hours per week) based on: active diagnoses; overall health status; technology dependency; amount and frequency of specialized skilled nursing interventions required; and amount of caregiver assistance available. Unused hours shall not be banked or rolled over.max 112/week

Section 3.4

Standard Level 1 approved hours by caregiver availability: Two or more fully available caregivers: up to 56 hours/week; One fully available caregiver: up to 84 hours/week; Two or more partially available caregivers: up to 104 hours/week; One partially available caregiver: up to 112 hours/week.

Section 3.4 Approved hours table

inv-07: Short-Term Increase (STI) for Significant Change in Condition

Covered when ONE of the following significant changes is met; STI limited to maximum 6 calendar weeks and requires prior approval

STI triggers: a) New tracheostomy, ventilator, or other life-sustaining medical technology need immediately post discharge requiring transition support and caregiver training; b) An acute, temporary change in condition causing increased amount and frequency of nursing interventions; c) A family emergency such as acute change in primary caregiver's ability to provide care or when secondary caregiver requires additional support or training reinforcement.max 6 calendar weeks

Provider must submit DMA-3511 and supporting documentation at least 5 business days prior to initiating STI; approval by NC Medicaid's PDN Nurse Consultant (Section 3.4.1).

inv-08: Therapeutic Leave

Covered when physician documents travel safety and need for nursing care

Therapeutic leave must be ordered by the attending physician; approval is limited to 14 days per calendar year and shall not exceed current approved hours; the attending physician must indicate the beneficiary can travel safely and requires nursing care during leave; documentation that a nurse must travel with the beneficiary must be included. The provider shall submit the attending physician-signed order at least five (5) business days prior to the leave request.max 14 days/year

Section 3.4.2

inv-09: Covered with criteria

PDN is covered when the beneficiary meets eligibility and clinical criteria and documentation/PA requirements; not covered under the specified conditions below.

General coverage prerequisites: Beneficiary must meet eligibility requirements in Section 2.0, meet the clinical criteria in Section 3.0, and not have duplicate services; service must not be experimental, investigational, or part of a clinical trial.

Section 4.1

inv-10: Operational Coverage Criteria and Processes

Conditions and processes governing changes, terminations, transfers, and continuation of PDN services

Emergency changes: Emergency increases in services must be based on true emergent medical necessity; changes initiated outside regular business hours must be reported to NC Medicaid the next business day; written request must include specifics of condition change and a documented supplemental verbal order signed by an RN; an attending physician-signed order must be provided within five (5) business days.5 business days

Section 5.2.3.2

Termination: If PDN provider discharges beneficiary, submit DMA-3513 within five (5) business days; if attending physician discharges beneficiary, submit attending physician's order and DMA-3513 within five (5) business days; loss of Medicaid eligibility or 30+ day hospitalization requires re-initiation of prior approval.5 business days; 30 consecutive days

Section 5.2.4.1

Reduction notification:

inv-11: Provider and Caregiver Eligibility and Requirements

Covered when ALL of the following provider and caregiver requirements are met

Provider enrollment and accreditation: Provider must meet Medicaid participation qualifications, have a current signed DHHS Provider Administrative Participation Agreement, bill only within scope of practice, be accredited by Joint Commission, CHAP, or ACHC (or Medicare Certified Home Health Agency for Eastern Band of Cherokee), hold an N.C. DSHR license as applicable, be an enrolled N.C. Medicaid PDN provider, and each office must have an individual NC Medicaid PDN NPI.

Sections 6.0–6.1

Provider responsibilities and staffing: Ensure qualified and competent licensed nurses are assigned per the plan of care; perform orientation and competency assessment before assignment; maintain documented continuing education for RNs/LPNs; retain documentation of training and competency in personnel files.

Section 6.2

Supervisor qualifications: PDN nurse supervisor must have at least two (2) years of ICU/CCU/NICU/PICU or other critical care experience or two (2) years' home care experience with medically fragile beneficiaries, or a combination thereof; additional direct clinical supervisory experience is preferred.

inv-12: Provider and caregiver conditions for covered PDN

Covered when PDN services meet medical necessity and provider requirements:

Provider responsibilities: PDN service provider must provide and document training and education to the beneficiary, family, and designated caregivers; document caregiver competency to provide care when PDN nurse is not present; develop an emergency plan of action known to family/caregivers; evaluate home and family environment for health and safety prior to and during PDN services; comply with Patient Self Determination Act requirements; and avoid marketing or enticement practices.

Sections 7.4.2–7.6

Caregiver employment allowance: Agencies may allow employees who are the beneficiary's near relative or legally responsible person to deliver PDN skilled nursing services only if that individual holds a valid current nursing license and operates within their scope of practice. However, NC Medicaid shall not cover PDN if the PDN service provider is owned by the beneficiary's near relative or legally responsible person.

Information and amendments dated 02/15/2024 and 05/15/2024

inv-13: Billing Units and Authorization

Coverage and billing constraints for PDN services

Billing unit and authorization limits: PDN services are billed in 15-minute units and billed time cannot exceed the number of units per week authorized by NC Medicaid. The qualifications of the nurse shall be specified when billing.15-minute units; authorized weekly units

Sections D and Unit Limitations

inv-14: Coding Specificity and Modifiers

Coding and modifier requirements

Code specificity and modifiers: Report the most specific CPT/HCPCS/ICD-10 codes that accurately describe the services; use HCPCS code T1000 for PDN nursing services; apply modifiers TD for RN care and TE for LPN care. If no specific code exists, use the appropriate unlisted code per CPT/HCPCS instructions.

Sections C and D

inv-15: Program Integrity and Documentation

Program integrity and documentation

Documentation supports medical necessity: Services must be performed as documented on the CMS-485; services provided without authorization or services that are not medically necessary or not performed as documented may be investigated by NC Medicaid's Office of Compliance and Program Integrity and may result in recoupment of reimbursement; licensed nurses who falsify records are referred to the N.C. Board of Nursing or appropriate registry.documented on CMS-485

Program Integrity subsection

Observation-only presence of a nurse that is intended solely to monitor and intervene only if an event occurs does not meet the policy definition of complex skilled nursing. Such observation in case an intervention is required is explicitly not covered by Medicaid as medically necessary PDN services.

Medicare Qualified Beneficiaries (MQB) are not eligible for PDN under this policy. Beneficiaries who meet the MQB category should not be approved for PDN services.

PDN shall not be covered when the beneficiary is receiving medical care in institutional or staffed residential settings. Examples include a hospital, nursing facility, outpatient facility, or residential-type medical setting where licensed personnel are employed and have responsibility for the beneficiary's care; PDN is similarly not covered when the beneficiary resides in an adult care home, group home, family care home, or nursing facility.

Home Health and Home Infusion services are considered duplicative when PDN is providing enteral or parenteral nutrition or administering infusions. The DME supplier is responsible for providing enteral/parenteral nutrition equipment, supplies, and nutrients, and Home Health nursing may not be provided concurrently with PDN services.

PDN is not covered when the beneficiary is in a hospital, nursing facility, outpatient facility, or other residential-type medical setting where licensed staff are employed and have prescribed responsibility for the beneficiary's care. Claims for PDN in these settings are excluded under this policy.

NC Medicaid will not cover PDN when the PDN service provider is owned by the beneficiary's near relative or legally responsible person (for example: spouse, child, parent, grandparent, grandchild, or sibling, including step- and in‑law relationships).

Billed PDN time cannot exceed the number of units per week authorized by NC Medicaid. Providers must not submit claims for more units than were authorized for the beneficiary's approved week.

Interventions that do not require assessment or clinical judgment by a licensed nurse are not considered substantial nursing care and therefore do not meet the substantial skilled nursing requirement for PDN coverage.

No additional specific criteria apply for subsection 3.2.1; the document states None Apply for that subsection.

PDN is not covered if the beneficiary fails to meet the policy's eligibility or clinical criteria, if the service duplicates another provider's services, or if the procedure/product/service is experimental, investigational, or part of a clinical trial.

A PDN nurse may not transport the beneficiary. A licensed nurse may accompany or travel with the beneficiary only when medically necessary as defined elsewhere in the policy and when the beneficiary's normal life activities require access to the community within the NC Medicaid approved PDN schedule.

Coding and Billing

Referenced coverage policies for suppliesmixed

No codes listed

Program Description / PDN Nursing ServicesHCPCSCovered

T1000

PDN Nursing Services

HCPCS CodesHCPCSCovered

T1000

PDN Nursing Services

Unlisted Procedure or Servicemixed

CPT unlisted	Unlisted Procedure or Service — follow CPT instructions and Special Report
HCPCS unlisted	Unlisted Procedure or Service — follow HCPCS instructions and Special Report

Ventilator dependence threshold for Level 1

Ventilator dependence threshold (Level 1)Dependent on a ventilator for at least eight (8) hours per day.

Alternate Level 1 criteriaEligibility may also be met by meeting at least four listed Level 1 criteria (see Level 1 criteria in policy).

Reference sectionPolicy Section 3.3.1 (PDN Level 1 Services).

Documentation upload interval

Documentation upload intervalDMA-3509 and attending physician-signed CMS-485 must be uploaded every 60 days during the 180-day PA period.

PA day submission checkpoints

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Approval Required

Medicaid requires prior approval (PA) before rendering Private Duty Nursing (PDN) services. Prior approval is granted based on medical necessity and caregiver availability only and does not guarantee payment or ensure beneficiary NC Medicaid eligibility on the date of service. All service requirements must be met for payment.

Prior approval is required before initiating PDN services; initial provisional approvals may be granted for 30 calendar days pending receipt of full documentation.
PA is based on medical necessity and caregiver availability; PA is not a guarantee of payment or eligibility.

Billing Rule

Orders, Prior Authorization, and Billing Codes

PDN must be ordered by the beneficiary's attending physician (MD or DO) on the CMS-485 (Home Health Certification and Plan of Care Form). Prior authorization requests must include the required supporting forms and documentation (e.g., DMA-3508, DMA-3509, DMA-3511, DMA-3512, DMA-3513) as applicable. Use HCPCS code T1000 for PDN nursing services and bill medical supplies per the Home Health Fee Schedule and relevant HCPCS supply codes.

Background

Private Duty Nursing (PDN) is defined as substantial, complex, and continuous skilled nursing provided for beneficiaries who require more individualized and continuous care than visiting nurses or routine facility nursing staff can deliver. PDN must be medically appropriate and necessary, be directed by a written individualized plan of care, and be authorized by the beneficiary's primary physician.

Definitions

Skilled Nursing

Skilled Nursing (definition)Assessment, judgment, intervention, and evaluation by RN or LPN under RN supervision; includes assessment, planning, intervention, collaboration, implementation of prescribed regimens, teaching, recording, and maintenance of safe and effective care; excludes tasks delegable to unlicensed personnel per NC Board of Nursing rules.

Included activitiesAssessing physical/mental health, recording/reporting assessments, planning/initiating/delivering/evaluating nursing acts, collaborating with other providers, implementing treatment regimens, teaching/counseling, and documenting care and responses.

ExclusionsSkilled nursing does not include tasks delegable to unlicensed personnel per 21 NCAC 36 .0224, 36 .0225, and 10A NCAC 13J.1102 for In-Home Aide.

Nursing Care Activities (tasks)

Nursing Care Activities (tasks)Activities as defined by 21 NCAC 36 .0401; referred to as 'tasks' in this policy.

Policy Summary

PayerAlliance Health

PolicyPrivate Duty Nursing (PDN) for Beneficiaries Age 21 and Older

Policy CodePolicy 3G-1

Change TypeAmendment (May 15, 2024)

Effective Date

Next Review Date

Key ActionSubmit required prior approval forms (e.g., DMA-3508/DMA-3511, CMS-485) and supporting documentation before initiating PDN or short-term increases.

SourceLink

On This Page

When PDN services are reduced by provider or attending physician, notify NC Medicaid and submit the attending physician's order and DMA-3511 within five (5) business days. If NC Medicaid requests additional information, provider must supply it within 10 business days or agreed timeframe or NC Medicaid may proceed with reduction.

5 business days; 10 business days

Transfers between branches: Initiating branch must coordinate transfer, notify NC Medicaid, and submit required documentation at least five (5) business days prior to branch transfer; attending physician-signed order with new PA entry required; current branch shall upload DMA-3513 to their approved PA.5 business days

Section 5.2.5.1

Transfers between agencies and shared care: Transfer provisional approval may be granted for 30 calendar days pending required documentation. For transfer continuation or shared continuation approval, required documentation (attending physician-signed CMS-485 and consent to treat) must be submitted by PA day 30 to allow continuation for remainder of the 180-day PA period; required documentation for shared provisional review must be submitted at least five (5) business days prior to requested start. Incomplete or omitted documentation may result in denial.30 calendar days; 5 business days; PA day 30; 180-day PA

Sections 5.2.5.1, 5.2.5.3, 5.2.5.5, 5.2.5.6

Redistribution of shared hours: Initiating provider must submit DMA-3512 to approved PA at least five (5) business days prior to requested start; NC Medicaid will review and late submissions may only be considered from date of request submission.5 business days

Section 5.2.5.7

Coordination and notification: Attending physician and PDN provider are responsible for monitoring care and initiating changes; notify NC Medicaid within five (5) business days when beneficiary transfers between healthcare settings.5 business days

Sections 5.2.5 and 5.2.4

Concurrent services and supplies: DME supplier provides infusion and nutrition equipment and supplies; PDN provider administers infusions and provides caregiver teaching; home health nursing may not be provided concurrently with PDN; PDN provider shall provide and bill for medical supplies per applicable coverage policies.N/A

Sections 5.2.6.2–5.2.6.5

Unauthorized hours: PDN services provided in excess of the approved amount are the financial responsibility of the PDN service provider.Approved amount

Section 5.3.1

Caregiver requirements: Beneficiary must have at least one primary trained informal caregiver (PDN not approved without one); a secondary/back-up trained informal caregiver is recommended; family or designated caregivers must demonstrate and have documented competency.

Sections 3.2.2.f and 7.4.1–7.4.3

Documentation and coordination: Provider must document daily beneficiary/caregiver acknowledgement of services and use of medical supplies, perform supervisory visits, coordinate with other homecare services, and submit medical update/face-to-face encounter documentation with each reauthorization.daily signature

Sections 7.2.1 and 5.2.2.4–5.2.2.5

By PA day 60 and PA day 120: DMA-3509 and attending physician-signed CMS-485 must be submitted.

Reauthorization lead timeReauthorization requests must include required documents at least 15 business days prior to PA end date.

Therapeutic leave maximum duration

Therapeutic leave maximum durationApproval limited to 14 days per calendar year and shall not exceed current approved hours.

Physician order requirementAttending physician must order therapeutic leave and indicate beneficiary can travel safely and requires nursing care.

Submission timingPDN provider shall submit attending physician-signed order at least five (5) business days prior to the therapeutic leave request.

Comprehensive assessment timing

Comprehensive assessment timingPDN service provider shall complete a comprehensive assessment within 48 hours of the start of care (SOC).

Action after assessmentEnter a request for prior authorization by submitting required documents for initial provisional review following the assessment.

Referenced formInitial referral documentation requirements in Subsection 5.2.2.2 support the assessment and PA request process.

Hospitalization trigger / PA re-initiation

Hospitalization trigger / PA re-initiationIf no PDN services are provided during 30 consecutive days for any reason, including hospitalization, the prior approval process must be initiated again.

Provider notification requirementPDN service providers shall notify NC Medicaid when a beneficiary is hospitalized for 30 days or greater.

Transfer provisional timingTransfer provisional approvals may be granted for 30 calendar days pending required documentation submission.

Provisional approval length

Provisional approval lengthProvisional (initial or transfer/shared) approval may be granted for 30 calendar days pending receipt of required documentation.

Continuation after provisionalContinuation approval may be granted for the remainder of the 180-day PA period once required documentation is received by PA day 30.

Provisional conditionsProvisional approvals are contingent upon submission of attending physician-signed CMS-485 and other specified documents.

PA period length

PA period lengthThe PA period is a maximum of 180 days (180-day PA period).

Documentation cadence within PAAttending physician-signed CMS-485 and DMA-3509 must be uploaded every 60 days during the 180-day certification period.

Continuation/transfer/shared approvalsTransfer and shared continuation approvals may be granted for the remainder of the 180-day PA period upon timely submission of required documents by PA day 30.

Notification timeframe after device no longer required

Notification timeframe after device no longer requiredWithin 10 business days, the PDN service provider shall notify NC Medicaid and submit DMA-3511, supporting documentation, and updated physician orders when a beneficiary no longer requires the medical device.

Purpose of notificationNotification initiates re-evaluation of continuation of PDN services after device weaning.

Form requiredDMA-3511 (PDN Change Request Form) is the required change notification form.

Clinical record retention

Clinical record retentionClinical records shall be retained for six (6) years after the discharge of the beneficiary.

Notification if agency ceases operationsIf an agency ceases operation, NC Medicaid shall be notified in writing where the records are stored.

Governing agreementRetention in accordance with DHHS Provider Participation Agreement.

Coding specificity

Coding specificity requirementReport ICD-10-CM and PCS to the highest level of specificity that supports medical necessity and use the current ICD-10 edition in effect at the time of service.

Use of current editionsProviders shall use the current ICD-10 edition and any subsequent editions in effect at the time of service and refer to that edition for code descriptions.

Relation to plan of careServices must be documented on the CMS-485 consistent with performed services and coded to support medical necessity.

Order: CMS-485 signed and dated by attending physician (or RN verbal order with RN signature and later attending signature where allowed).
Initial provisional requests: DMA-3508 (PDN Referral Form) + recent H&P or hospital records.
Short-term increases: DMA-3511 (PDN Change Request Form).
Shared care: DMA-3512 (PDN Shared Case Form).
Discharge/transfer: DMA-3513 (PDN Discharge Summary Form).
Billing: HCPCS T1000 for PDN services; supplies billed with HCPCS supply codes per Home Health Fee Schedule.

Billing Rule

Authorization of Weekly PDN Units

Approved PDN hours are authorized and recorded as units per week. Billed time cannot exceed the number of units per week authorized by NC Medicaid. Hours are approved on a per-week basis (12:01 a.m. Sunday to 12:00 a.m. Saturday) and unused hours do not roll over.

Unit limits: Billed time must not exceed authorized units per week.
Week definition: 12:01 a.m. Sunday through 12:00 a.m. Saturday.
Unused hours cannot be banked or rolled over.

Note

PA Is Not a Payment Guarantee

Prior approval is not a payment guarantee. Providers must verify beneficiary Medicaid eligibility, ensure all service conditions are met, and submit required documentation timely to receive payment. Services provided without authorization or not medically necessary are subject to investigation and potential recoupment.

Verify NC Medicaid eligibility and coverage category before initiating services and during delivery.
PA does not ensure payment — all documentation and service requirements must be met.
Program Integrity: unauthorized or undocumented services may be referred for recoupment and investigation.

Denial Risk

Medical Settings Exclusion

PDN is covered only in the beneficiary's private primary residence. Services provided in hospitals, nursing facilities, outpatient facilities, or residential-type medical settings where licensed personnel provide care are not covered and risk denial.

Place of service requirement: private primary residence only.
Normal life activities away from residence (school, work, licensed childcare, religious activities) are allowable; care in inpatient or residential medical settings is not covered.

Denial Risk

Incomplete PA Requests May Be Denied

Incomplete PA requests or requests for additional information not received within the specified timeframe are handled as incomplete and may result in denial. Providers must submit all required documents (including DMA forms, CMS-485, H&P, nursing notes, and employment verification when applicable) within the timelines stated for provisional and continuation reviews.

Initial provisional review: submit DMA-3508 and recent H&P; missing information may cause denial.
Continuation and reauthorization: submit attending physician-signed CMS-485 and DMA-3509 every 60 days; by PA day 30 submit required continuation documents.
Transfer/shared care: submit required DMA forms at least 5 business days prior to requested start date; incomplete submissions may lead to denial.

Prior Authorization

Therapeutic Leave Documentation

Therapeutic leave (including vacation) must be ordered by the attending physician and is limited to 14 days per calendar year, not exceeding current approved hours. The physician must state the beneficiary can travel safely and requires nursing care; if a nurse must travel, that necessity must be documented. Submit the attending physician-signed order at least five (5) business days prior to the therapeutic leave.

Therapeutic leave limited to 14 days/year and not to exceed current approved hours.
Physician order must document safe travel and need for nursing care; document nurse travel necessity if applicable.
Submit physician-signed order to NC Medicaid at least 5 business days prior to leave.

Prior Authorization

Initial Provisional Documentation

Initial provisional approval may be granted for up to 30 calendar days pending receipt of required documentation. For initial provisional review, submit DMA-3508 (PDN Referral Form) signed by the attending physician and a recent history & physical (or hospital progress notes/discharge summary if discharged from hospital). The PDN provider must complete a comprehensive assessment within 48 hours of the start of care.

Comprehensive assessment by PDN provider within 48 hours of SOC.
Initial provisional documentation (within 60 days): DMA-3508 + recent H&P or hospital records.
If requested after SOC date, PA will only be considered from the date of request submission.

Prior Authorization

Required Documents for Transfers / Shared Care

Transfers between branches or agencies and shared care arrangements have specific required documents and timelines. For branch-to-branch transfers, submit an attending physician-signed order with a new PA entry and upload DMA-3513 (PDN Discharge Summary). For transfers between different agencies or shared care, submit DMA-3508 (attending physician-signed), DMA-3512 (PDN Shared Case Form) when applicable, and any required insurance documentation at least five (5) business days prior to the requested start date. Continuation documentation (attending physician-signed CMS-485 and consent to treat) must be submitted by PA day 30.

Branch transfers: attending physician-signed order (addendum or updated CMS-485) + DMA-3513 uploaded to approved PA.
Agency transfers: provisional approval up to 30 days; submit DMA-3508 and insurance documentation ≥5 business days prior.
Shared care: submit DMA-3508 and DMA-3512 and required insurance docs ≥5 business days prior; NC Medicaid processes continuation within 5 business days of receiving all information.
By PA day 30 for transfers/shared continuation: attending physician-signed CMS-485 and PDN provider consent to treat.

Documentation Required

Required Clinical Record Contents

Maintain complete clinical records documenting the date/time of skilled care, all nursing interventions and beneficiary responses, certification that care followed physician orders and approved plan of care, daily beneficiary/caregiver acknowledgement signatures, place of service if outside the residence, use of supplies, reports given/received, caregiver availability, caregiver training and competency documentation, safety issues and interventions, coordination with other home services, documentation of medical updates, and supervisory visits per agency policy and licensure rules.

Document date/time of skilled care and detailed nursing interventions and beneficiary response.
Certify care was provided per attending physician orders, plan of care, and NC Medicaid approval.
Obtain daily signature of beneficiary or caregiver acknowledging services rendered.
Include documentation of place of service for care delivered outside residence, supply usage, report handoffs, present/available caregivers, caregiver training and competency, safety issues, coordination with other services, medical updates for reauthorization, and supervisory visits.

Documentation Required

Record Retention and Termination

If an agency ceases operations, notify NC Medicaid in writing where records are stored. Clinical records must be retained for six (6) years after beneficiary discharge in accordance with DHHS Provider Participation Agreement.

Notify NC Medicaid in writing of storage location if agency terminates operations.
Retain clinical records for six (6) years after beneficiary discharge.

Documentation Required

Training, Competency Documentation, and Coding Specificity

PDN providers must document training and education provided to beneficiaries, family members, and designated caregivers, and must document caregiver competency to perform care when PDN staff are absent. Providers must report ICD-10-CM, PCS, CPT, and HCPCS codes to the highest level of specificity available and use current code editions. If no specific CPT/HCPCS code exists, report services with the appropriate unlisted code.

Document training provided and competency demonstrations by family or designated caregivers; include hospital discharge teaching when applicable.
Report ICD-10-CM/PCS and CPT/HCPCS to the highest specificity using current editions.
Use unlisted procedure codes when no specific code exists.

Note

Supplemental Care Consideration

PDN is considered supplemental to care provided by family, foster parents, and delegated caregivers. Providers must indicate all caregivers available to supplement care and document the status of training provided. PDN cannot be approved if no trained primary informal caregiver is available.

PDN is supplemental — document available caregivers and their training status.
At least one trained primary informal caregiver is required; lack of an available trained caregiver precludes approval.
NC Medicaid may request verification of caregiver employment schedules annually.

Documentation Required

Ongoing Documentation Cadence

Throughout the authorization period providers must follow the ongoing documentation cadence: upload the attending physician-signed CMS-485 and DMA-3509 (PDN Medical Update Form) every 60 days during the 180-day PA period. Specifically, submit DMA-3509 and physician-signed CMS-485 by PA day 60 and PA day 120, and ensure all attending physician-signed CMS-485s for the 180-day certification period are uploaded before PA expiration. Verbal RN orders with RN signature may be used temporarily if an attending physician signature is pending, but the attending physician-signed CMS-485 must be obtained and uploaded within the certification timeframe.

Upload attending physician-signed CMS-485 and DMA-3509 every 60 days during the 180-day PA period.
By PA day 60 and PA day 120: submit DMA-3509 and attending physician-signed CMS-485.
Verbal RN order with RN signature is acceptable temporarily if attending physician signature is pending; all attending physician-signed CMS-485s for the 180-day period must be uploaded before PA expiration.

Policy usageThe policy uses the regulatory definition from 21 NCAC 36 .0401 to define nursing care activities.

ImplicationTasks delegable to unlicensed personnel are excluded from skilled nursing coverage.

Substantial

Substantial (definition)Need for interrelated nursing assessments and interventions; interventions not requiring assessment/judgment by a licensed nurse are not considered substantial.

Coverage implicationActivities that do not require licensed nurse assessment/judgment will not meet the substantial skilled nursing requirement for PDN coverage.

Regulatory basisDefined within policy Section 1.1.3 referencing interrelated assessments and interventions.

Complex

Complex (definition)Scheduled, hands-on nursing interventions; mere observation in case an intervention is required is not considered complex skilled nursing.

Coverage exclusionObservation-only purposes do not qualify as complex skilled nursing and are not covered by Medicaid as PDN services.

Policy locationDefined in Section 1.1.4 of the policy.

Continuous

Continuous (definition)Skilled nursing assessments requiring interventions are performed at least every two (2) hours during the period Medicaid-covered PDN services are provided.

Operational implicationContinuous PDN requires nursing assessments at a minimum two-hour frequency during covered service periods.

Policy referenceSection 1.1.5 (Continuous) of the policy.

Significant Change in Condition

Significant Change in ConditionA change that is not self-limiting, impacts more than one area of functional health status, and requires multidisciplinary review or revision of the plan of care; may trigger STI or re-evaluation and documentation requirements.

STI limitShort-term increases for significant change are limited to a maximum of 6 calendar weeks and require prior approval (see Subsection 3.4.1).

Notification/DocumentationSignificant change triggers re-evaluation and may require submission of DMA-3511 and supporting documentation per policy procedures.

Continuous

Continuous (repeated)Skilled nursing assessments requiring interventions are performed at least every two (2) hours during the period Medicaid-covered PDN services are provided.

Minimum frequencyAssessments and interventions must occur at least every two hours during covered PDN service periods.

ReferenceSection 1.1.5 (Continuous).

Significant Change in Condition

Significant Change in Condition (repeated)A change in beneficiary status that is not self-limiting, impacts more than one area of functional health status, and requires multidisciplinary review or revision of the plan of care.

Triggers for actionMay necessitate submission of supporting documentation and prior approval for short-term increases or adjustments to the plan of care.

Policy sectionSection 1.1.6.

Primary and Secondary Caregivers

Primary and Secondary CaregiversPrimary caregivers are trained informal caregivers living with the beneficiary; distinctions include fully available, partially available, and secondary/back-up caregivers with respective availability definitions.

ExpectationAll parents, guardians, or legally responsible persons residing in the home are expected to serve as a trained, informal caregiver.

DocumentationCaregiver competency and availability must be documented as part of required records and PA submissions.

PDN not covered when institutional care or staffed residential settings provide care

PDN not covered in institutional/staffed residential settingsMedicaid does not cover PDN when the beneficiary is receiving care in settings with licensed personnel employed (hospital, nursing facility, outpatient facility, residential medical setting) or resides in adult care homes, group homes, family care homes, or nursing facilities.

Related exclusionsPDN is also not covered for services that are custodial, observation-only, or duplicative of home health/infusion services during the same hours.

Policy referenceSection 4.2.2 (Medicaid Additional Criteria Not Covered).

Durable Medical Equipment (DME) supplier

Durable Medical Equipment (DME) supplier roleDME supplier provides infusion and enteral/parenteral nutrition equipment, supplies, and nutrients; the PDN service provider is responsible for administration and caregiver teaching for infusions.

Duplication avoidanceHome Health and Home Infusion would be considered duplication of services when PDN provides enteral/parenteral nutrition or infusion administration.

Billing for suppliesWhen Home Health medical supplies are required, the PDN provider shall provide and bill for those supplies as appropriate.

Home Health nursing

Home Health nursingHome Health nursing services may not be provided concurrently with PDN services; PDN providers should perform home health nursing tasks (blood draws, wound care) and bill for medical supplies when required.

Concurrent services exclusionConcurrent home health nursing during the same hours as PDN is not allowed (see exclusions).

Provider responsibilityPDN providers expected to perform home health tasks and provide supplies when PDN beneficiary requires them.

Near relative / legally responsible person ownership

Near relative / legally responsible person ownershipPDN is not covered if the PDN service provider is owned by the beneficiary's near relative or legally responsible person (spouse, child, parent, grandparent, grandchild, or sibling, including step- and in-law relationships).

Employment allowanceAgencies at their discretion may allow employees who are near relatives or legally responsible persons to deliver PDN if they hold a valid current nursing license and operate within scope of practice.

Policy change notePolicy language replaced prior blanket prohibitions with allowance for licensed near relatives to provide care under conditions.

Private Duty Nursing (PDN)

Private Duty Nursing (PDN) definitionPDN is substantial, complex, and continuous skilled nursing care defined by 42 CFR 440.80; provided for beneficiaries who may require more individual and continuous care than is available from a visiting nurse or routinely provided by hospital/skilled nursing facility staff. PDN care must be medically appropriate and medically necessary.

ScopePDN is supplemental to care provided by family, foster parents, and delegated caregivers as applicable.

Policy citationSection 1.0 and amendment history (02/15/2024) reflect updated PDN definition referencing 42 CFR 440.80.