Private Duty Nursing
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Defines Medicare Plus Blue coverage, payment conditions, clinical criteria, billing and documentation requirements for private duty nursing (PDN) provided in the home for Medicare Advantage members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Private Duty Nursing
inv-01: General criteria
Covered when ALL of the following are met
inv-02: Specific clinical criteria
AND all of the following specific clinical/documentation criteria are met
The following services are explicitly excluded from coverage: care provided by the patient’s relative, care provided by a hospital employee, housekeeping, laundry, respite care, services not medically necessary, taxes, and travel expenses.
These Medicare Advantage Enhanced Benefit policies describe the criteria BCBSM/BCN use to determine reasonable and necessary services when Medicare rules are not fully developed. They are not an authorization, certification, explanation of benefits, or a contract and do not guarantee payment. Providers must review member benefit documents and applicable reimbursement and provider manual guidance before billing; enhanced benefit policies do not replace independent clinical judgment.
Services that are not medically necessary are excluded from coverage. Claims for such services will not be covered under this PDN benefit.
Coding and Utilization Details
| No codes listed |
Provider Actions, Documentation & Billing
Verify coverage, authorizations and payment
Coverage/payment is determined by the member's plan and fee schedule. Providers must verify authorization, coverage and the plan’s maximum payment amount through the BCBSM/BCN provider portals before delivering or billing services.
- Verify Medicare Plus Blue PPO Enhanced Benefit Fee Schedule via Availity Essentials™ (Secure Provider Resources → Fee Schedules).
- Payment = lesser of allowed amount or provider charge, minus member cost share; providers may not balance-bill the member.
Review reimbursement policies before billing
All providers are required to review applicable BCBSM reimbursement policies and the provider manual before submitting claims. Failure to follow BCBSM/BCN reimbursement policies or provider manual requirements may result in unpaid or denied claims.
- Review BCBSM reimbursement policies relevant to Private Duty Nursing prior to claim submission.
- Contracted providers: review the BCBSM/BCN Medicare Advantage provider manual for additional claim submission requirements.
- Non‑contracted providers: be prepared to submit supporting documentation (including medical records) if requested.
Excluded services may be denied
Do not submit claims for excluded services. Claims for care provided by a patient’s relative, hospital employee, housekeeping, laundry, respite care, services not medically necessary, taxes, or travel expenses may be denied.
- Excluded services include: care by patient’s relative; care by hospital employee; housekeeping; laundry; respite care; non‑medically necessary services; taxes; travel expenses.
Ordering and caregiver training requirements
Private duty nursing services must be ordered by an MD or DO and the care plan must document training of caregivers. At least two caregivers (family member, friend, etc.) must be trained and competent to provide care when the nurse is not present.
- Order must be from the attending physician (M.D. or D.O.) involved in ongoing care.
- Document caregiver training and competency for at least two caregivers.
- Services are intended to be temporary with the goal of training caregivers to assume care as appropriate.
Required documentation and physician certification
Providers must maintain and submit the required documentation and periodic physician certification. Submit a physician certification letter every three months and include hourly medical documentation or nurse shift notes, physician certification statement (diagnosis, plan of treatment, specific nursing duties, explanation of medical necessity), and all supporting items listed below.
- Physician certification every 3 months indicating need for up to 24‑hour LPN/RN care and estimated length of care.
- Hourly clinical documentation of services and observations; if hourly notes are not available, submit nurse shift notes.
- Complete certification statement must include: member diagnosis; plan of treatment; specific nursing duties; explanation of medical necessity; service dates with week ending dates; attending physician name and degree.
- Include nurse identification details and hours worked: nurse name/degree/address; professional license number; driver’s license with photo ID and number; hours worked and dates of service; member name; attending physician’s name and degree.
- Send all supporting documentation to: Blue Cross Blue Shield of Michigan Imaging and Support Services, Attention: Medicare Advantage Private Duty Nursing, P.O. Box 32593, Detroit, MI 48232-0593.
Definitions
Background
Private Duty Nursing (PDN) provides individualized, continuous skilled nursing in the home for patients whose care needs exceed standard home health services. PDN is intended to restore or maintain maximal function, include caregiver training until competency is achieved, and is typically temporary with goals to transition care to trained caregivers when appropriate. Coverage determinations follow the clinical criteria and documentation requirements set by BCBSM/BCN and the member’s benefit plan.
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