Currentblue cross blue shield - tennesseePolicy N/A

Private Duty Nursing Home Plan of Care Agreement

Defines responsibilities, permitted services, exclusions, and signatures required for Medicaid Private Duty Nursing (PDN) provision in members' homes; applies to members receiving PDN under BlueCare Tennessee and related MCOs and their home health agencies, caregivers, and families.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPrivate Duty Nursing Home Plan of Care Agreement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain and follow a doctor's orders and ensure agency documents orders on the MAR and provides licensed, trained staff for PDN services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlymonthly supervisory visit

60 daysplan review contact

3 daysmissed shift reporting

2 weeksre-evaluation timing

Private Duty Nursing Coverage Criteria

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PDN coverage criteria

Covered when ALL of the following conditions are met:

PDN is ordered by the member's doctor and the member qualifies for Medicaid (BlueCare Tennessee/related MCO).

PDN is provided as in-home, hands-on skilled nursing (Private Duty Nursing, Skilled Nurse visits, or Home Health Aide services) for members who need more care than standard home health visits.

Goals of PDN include teaching the member and family to provide care, promoting independence, and setting PDN hours based on medical need over time.

ALL of the following

Excluded services include
- Non-medical services (examples: sitter, driver, respite care, general housekeeping, family meal preparation or family laundry).
- Services provided while the member is in a hospital or nursing home.
- Services when the member does not qualify for Medicaid or PDN.
- Observation/monitoring for behavioral or eating disorders or medical conditions that do not require skilled nursing care.
- Services that cannot be provided in a safe, complete and effective manner by home health staff (examples: uncontained weapons or animals, infestation with contagious pests, threatening or abusive behavior toward staff).

After a member turns 21, PDN is limited to certain conditions and for certain amounts of time per Medicaid rules; family members may need to provide more care at that point.

A backup caregiver/plan must be in place; the agency and MCO will assist when backup care or PDN cannot be provided. Members should not decline services for reasons other than quality concerns; if they do, they must secure another in-network agency and obtain new orders if needed.

Service Codes and Age-based Limits

Service typesmixed

	Home Health Aide
	Private Duty Nursing
	Skilled Nurse Visits
	HCBS services (Attendant Care/Personal Care Services)

inv-03: Age-based PDN limits

Age restrictionAfter a person turns 21, PDN is limited to certain conditions and for certain amounts of time; family members may need to help with care after age 21.

Medicaid requirementPDN is provided under Medicaid and members must follow Medicaid rules.

SettingPDN is for people who can safely be cared for in their home.

PurposeIntended for people who need more care than standard home health visits and to prepare families/members to provide care.

Authorization and Provider Responsibilities

Prior Authorization

Prior authorization and service limits

PDN services are limited to hands‑on skilled nursing care (provided by Home Health Aides, Skilled Nurses, or Private Duty Nurses) as ordered by a doctor; PDN does not cover non‑medical tasks such as laundry, cleaning, shopping, or pet care. After a member turns 21, PDN is only available for certain conditions and for limited lengths of time; Medicaid rules and family responsibilities apply.

Provider must follow physician orders for PDN services and restrict services to hands‑on skilled care.
Do not provide non‑medical tasks (e.g., laundry, cleaning, shopping, walking the dog) under PDN.
Verify Medicaid eligibility and applicable age‑based limits—after age 21 PDN availability is limited to certain conditions and durations.

Key Definitions and Exclusions

inv-05: PDN care is in-home skilled nursing for members requiring more care than home health visits and includes teaching members and families to provide care; not a replacement for family caregivers.

Definition of PDNPrivate Duty Nursing (PDN) is in‑home skilled nursing for members who need more care than home health visits and includes teaching members and families to provide care; it does not replace family caregivers.

Care goalsTeach and help the member care for themselves; teach and help family/others to provide care; support independence based on medical conditions.

Care planningPDN hours are based on medical need over time and the family/caregivers must provide backup care when needed.

Eligibility notePDN is for people who can safely be cared for in their home and is delivered under Medicaid rules.

inv-06: Excluded services

Non‑medical exclusionsNon‑medical services are not provided: examples include sitter, driver, respite care, general housekeeping, family meal preparation, and family laundry.

Setting exclusionsServices are not provided while the member is in the hospital or nursing home.

Eligibility exclusionsServices are not provided if the member does not qualify for Medicaid or PDN.

Observation‑onlyServices to observe or monitor behavioral or eating disorders or medical conditions that do not require skilled nursing care are excluded.

Unsafe conditionsServices that cannot be provided safely or effectively by home health staff (e.g., uncontained weapons/animals, infestations, threatening or abusive behavior) are excluded.