Private Duty Nursing (PDN)
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Defines clinical guidelines, acuity scoring, and coverage determination criteria for Private Duty Nursing services delivered in the home, DDS community provider facilities, or public school settings for eligible members under Arkansas PASSE.
Simplified D.I to refer to Provider Manual for eligibility and clarified skilled vs unskilled scoring and several point categories (e.g., stoma, insulin, ventilator, neurostorm, seizure sections).
Incontinence/toileting program scoring and updated references were added.
Coverage criteria for Private Duty Nursing (PDN)
PDN eligibility and acuity-based coverage
Use the PDN acuity scale together with the acuity assessment tool and the clinical judgment of the nurse completing the tool; normal age‑appropriate care and unskilled needs are excluded from scoring.
Acuity tool is not the sole determinant; consider normal age-appropriate care and exclude unskilled needs
Acuity scoring items for skilled nursing
Covered PDN/skilled services are scored by item. For many subsections select up to one option per listed item; sum applicable item scores to determine total acuity points.
Select up to one option per respiratory sub-item
Select up to one option per sub-item
Documentation required for aspiration/reflux criteria
Monitoring must be recorded in nurses' notes or logbook
Simple vitals alone do not earn points unless part of targeted assessment
Do not double-count decubitus/complex dressing with wound/stoma/medicated skin treatment
Select up to one option where subsections limit selection
Non-skilled nursing (caregiver availability)
Non-skilled caregiver availability scoring is used only when the member does not meet PDN by skilled score alone but significant extenuating psychosocial circumstances exist; the non‑skilled score may be added to the skilled score for total hours when allowed.
Non-skilled score is not routinely added when skilled score <15; only added when significant extenuating circumstances documented
Acuity scoring criteria
Total acuity points (sum of applicable skilled items and, when permitted, non‑skilled items) map to recommended hours of care. Point selections within subsections are subject to 'select up to one' rules where specified.
Use nurse clinical judgment and acuity assessment tool; documentation must support scored items (eg, logs, physician orders, nurse notes)
PDN above 112 hours/week are not routinely approved; extensions may be considered only for emergent short-term needs
Normal age-appropriate care and routine parental responsibilities are not scorable as medical PDN needs. For example, assistance with bathing and dressing that is expected for a typical 3‑year‑old would not be counted toward the PDN acuity score because it reflects developmentally appropriate help rather than a skilled nursing need. Likewise, unskilled tasks provided by family, a home health aide, waiver services, or other non‑nursing caregivers should not be scored as skilled PDN needs.
The RN or LPN who provides PDN services may not be a family member or a person acting as a family member. This includes the member's spouse, a minor’s parent (or anyone acting as the minor’s parent), a minor’s guardian (or anyone acting as the minor’s guardian), an adult’s guardian (or anyone acting as the adult’s guardian), or any person who resides with the client.
Services that are provided primarily for the convenience of the member or provider, or that do not meet the health plan's definition of medically necessary, are not authorized or payable. Medical necessity is determined by the plan contract / Evidence of Coverage and requires documentation that the service is proper and necessary for diagnosis or treatment and not mainly for convenience.
As a routine limit, PDN requests that would result in more than 112 hours per week are not routinely approved. Extensions beyond 112 hours per week may be considered only for documented emergent short‑term needs and on a case‑by‑case basis.
What providers must do / authorization & documentation
Tie prior authorization to PDN acuity assessment
Prior authorization for PDN must reference Arkansas provider manuals and administrative code and be based on the PDN acuity scale together with the acuity assessment tool and the clinical judgment of the nurse completing the tool; the acuity tool is not the sole determinant of skilled nursing need. Providers must consult the Arkansas administrative code and provider manuals for details about coverage, limitations, service conditions, and prior-authorization requirements.
- Use the PDN acuity scale plus the acuity assessment tool and nurse clinical judgment to support prior-authorization requests.
- Refer to Arkansas Medicaid Provider Manual Sections 200.000–242.440 for eligibility and prior-auth requirements.
Point-based authorization maps points to hours
Authorization is acuity-driven: total acuity points map to recommended daily hours of PDN and corresponding weekly hours; routine approvals generally stop at 112 hours per week.
- 15–24 points = 4–8 hours/day (less than 56 hours/week).
- 25–34 points = 8–12 hours/day (56–84 hours/week).
- 35–40 points = 12–14 hours/day (85–98 hours/week).
- 40+ points = up to 16 hours/day (99–112 hours/week).
Step therapy not specified
This policy does not specify any step therapy requirements for PDN services in this section of the document.
Follow Arkansas administrative code and provider manual documentation and assessments
Document the acuity assessment and the nurse's clinical assessment and notes per Arkansas administrative code and provider manuals; the acuity assessment tool must be used alongside clinical judgment when determining PDN need.
- Include completed acuity assessment tool in the record.
- Document nurse clinical assessment, visit notes, and any logs that support scored items.
Required documentation elements to support acuity scoring
Clinical records must include the specific documentation elements used to assign acuity points, for example caregiver employment/school status, how the member tolerated oral feedings, physician orders and nurse documentation for device application, range of motion, turning schedule, and skin assessments.
- Caregiver employment/school status when scoring caregiver availability.
- Documentation of tolerated oral feedings when oral feeding assistance is scored.
- Physician orders and nurse documentation for AFO/splint application, ROM, turns every 2 hours, skin assessments, and other scored interventions.
Authorization depends on medical necessity and the plan contract
Authorization and payment require that PDN services be medically necessary, supported by documentation, and consistent with the member's plan contract; medical policy statements do not override the plan contract if conflicts exist.
- Ensure documentation supports medical necessity per local standards and plan contract.
- If the Medical Policy Statement conflicts with the Evidence of Coverage (plan contract), the plan contract controls.
Denial triggers: excessive hours and ineligible settings
Denials are commonly triggered when requested PDN exceeds routine approval limits or services are provided in non-covered settings; PDN requests above 112 hours/week are not routinely approved, and PDN is not covered in hospital, boarding home, nursing facility, residential care facility, or assisted living facility.
- PDN above 112 hours per week are not routinely approved absent emergent short-term need.
- PDN services provided in a hospital, boarding home, nursing facility, residential care facility, or assisted living facility are not eligible for coverage.
Definitions and point-to-hours mapping
Background on Private Duty Nursing
Private Duty Nursing (PDN) refers to skilled nursing services provided by a registered nurse (RN) or licensed practical nurse (LPN) under physician direction for members who require continuous or more individualized care than routine visiting nurses or facility staff can provide. Coverage and hours are determined using the PDN acuity scale together with an acuity assessment tool and the nurse’s clinical judgment; the tool quantifies skilled and, in limited circumstances, non‑skilled caregiver availability to map total acuity points to an hourly PDN recommendation.
Policy revision history
Policy effective date set to July 1, 2026 following prior revisions and updates.
Review simplified the dependency on the Provider Manual for eligibility, clarified skilled vs unskilled scoring and several point categories (stoma, insulin, ventilator, neurostorm, seizure sections), separated impairments and behaviors, and updated references; approved at Committee.
Policy initially issued as a new policy and approved at Committee on July 3, 2024.
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