Private Duty Nursing (PDN) reimbursement
Customize your policy alerts
Sign up for AmeriHealth Caritas Policy RPC.0128.7100 alerts
Get alerted when Policy RPC.0128.7100 changes without checking for updates manually.
Monitor payer policy activity
Defines reimbursement rules, requirements, and prior authorization expectations for private duty nursing services billed to AmeriHealth Caritas Delaware; applies to providers submitting CMS-1500 or UB-04 claims for covered members.
Revised preamble.
Minor updates to formatting and syntax.
Removal of Applicable Claim Types table.
Coverage and Medical Necessity
PDN coverage criteria
Covered when ALL of the following are met:
ALL of the following
- Services must be provided by a registered nurse (RN) or licensed practical nurse (LPN).
- Services must be provided under the direction of the beneficiary's physician.
- Covered service locations (at the Plan's option) include the member's home, hospital, or skilled nursing facility.
- Reimbursement is based on units billed; one unit equals one hour.
- Prior authorization is required for hours of PDN provided.
- Reimbursement to participating providers is per their AmeriHealth Caritas Delaware contract.
- In making claim payment determinations the Plan may consider CPT, HCPCS, ICD-10-CM, fee schedules, documentation, member eligibility, provider contract, and other applicable policies and regulatory requirements.
Coding, Units, and Claim Forms
Provider Requirements and Billing Actions
Prior authorization required for PDN hours
Prior authorization must be obtained for the hours of private duty nursing (PDN) services provided to the member; reimbursement is based on units billed and one unit equals one hour.
- Prior authorization is required for hours provided.
Key Definitions
Policy History and Changes
Reimbursement Policy Committee approval recorded for the policy.
Minor updates to formatting and syntax.
Revised preamble.
Revised preamble.
Removal of policy implemented by AmeriHealth Caritas Delaware from Policy History section.
Template revised; removal of Applicable Claim Types table, Coding section renamed to Reimbursement Guidelines, and Associated Policies section added.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.