CurrentMedStar Family Choice MarylandPolicy 1426

Private Duty Nursing Care

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This policy governs when MedStar Family Choice may approve hourly registered nurse or licensed practical nurse services provided in a member's home. It applies in Maryland and does not cover private duty nursing for adults age 21 and older.

Policy Summary

PayerMedStar Family Choice Maryland

PolicyPrivate Duty Nursing Care

Policy CodePolicy 1426

Change TypeAdministrative clarificationno material clinical or coverage change

Effective DateJuly 1, 2026

Last ReviewJul 1, 2025

Next Review DateNot specified

Key ActionObtain prior authorization for both new and continuing private duty nursing requests, with the required current orders and clinical documentation.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies the employment documentation required when continued private duty nursing hours are requested for a working primary caregiver.

The policy clarifies that renewal nursing documentation must record the presence or absence of primary caregivers and other adults or children during each service date.

The policy scope expressly identifies Maryland.

The current revision updated COMAR references and corrected punctuation.

21+Private duty nursing not covered at age

30 daysNew-request documentation limit

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CurrentMedStar Family Choice MarylandPolicy 1426

Private Duty Nursing Care

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Sign up for medstarfamilychoicemaryland Policy 1426 alerts

Get alerted when Policy 1426 changes without checking for updates manually.

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Policy Summary

PayerMedStar Family Choice Maryland

PolicyPrivate Duty Nursing Care

Policy CodePolicy 1426

Change TypeAdministrative clarificationno material clinical or coverage change

Effective DateJuly 1, 2026

Last ReviewJul 1, 2025

Next Review DateNot specified

Key ActionObtain prior authorization for both new and continuing private duty nursing requests, with the required current orders and clinical documentation.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies the employment documentation required when continued private duty nursing hours are requested for a working primary caregiver.

The policy clarifies that renewal nursing documentation must record the presence or absence of primary caregivers and other adults or children during each service date.

The policy scope expressly identifies Maryland.

The current revision updated COMAR references and corrected punctuation.

21+Private duty nursing not covered at age

30 daysNew-request documentation limit

Renewal documentation limit

40 hr/weekRoutine weekly authorization limit

24 hr/dayShort-term daily authorization limit

8 hr/nightOvernight authorization limit

Private Duty Nursing Coverage Criteria

Initial or new request

New requests are covered when ALL of the following conditions are met.

New request requirements

Current order and clinical need: A treating practitioner order is written within 30 days of the anticipated start of service, the treating practitioner's notes are no older than 30 days and clearly document private duty nursing as part of the treatment plan, and the requested care is medically necessary and consistent with accepted medical practice.30 days
Caregiver availability and training: At least one caregiver is willing and able to assume responsibility when the nurse is unavailable, and services include teaching and supervision while caregivers practice the skills needed to care for the member.
No approval if no willing and able caregiver exists.
Need for skilled substitution: The primary caregiver cannot provide all required care solely because the caregiver lacks the necessary skills, the member requires an awake and alert caregiver at all times, or a nurse is needed to permit qualifying caregiver employment or schooling.
Care cannot be requested solely for convenience or preference.
Skilled service need: The member needs a licensed nursing professional for one or more qualifying services and no alternative timing of services can be arranged.
See the qualifying skilled services criteria.

Caregiver substitution

Caregiver substitution for employment or schooling is covered only when the applicable circumstance and documentation requirements are met.

Qualifying caregiver substitution circumstance

Sleep relief: The member requires an awake and alert caregiver at all times and the primary caregiver needs sufficient time to sleep each day.
Employment: A nurse is required to allow the primary caregiver to work, supported by employer documentation or, if self-employed, at least three qualifying business or tax documents.
Employer documentation must be on company letterhead and include the caregiver's job title, work dates and hours, work location, and employer contact information. Self-employed caregivers must submit at least three qualifying business or tax documents.
Qualifying schooling: A nurse is required to allow the primary caregiver to attend a GED, high school diploma, associate's degree, or first-time bachelor's degree program, supported by institutional documentation showing enrollment and the exact course dates, times, and locations.

Qualifying skilled services

When substituting for the primary caregiver, the member must require a skilled nursing service and no alternative timing may be arranged.

Complex clinical services: The services include infusion initiation, blood product administration, medication pump programming other than routine insulin through a programmed pump, tracheostomy care, ventilator care, suctioning, gastrostomy tube feeding or care, medication administration by gastrostomy tube, sterile procedures, complex wound care, or indwelling catheter care.
Teaching or other licensed-nursing service: The services include teaching or training related to medication regimens, disease processes, or safety, or another service for which a licensed nursing professional is required.

Continuation or renewal

Continuing requests are covered when ALL of the following conditions are met.

Renewal requirements

Current practitioner documentation: The treating practitioner documents that private duty nursing remains medically necessary, provides an updated plan of care, and issues an order within 60 days of the anticipated renewal date.60 days
Recent service records: Complete and comprehensive nursing documentation from services provided within 30 days of anticipated renewal demonstrates continuing need and includes service times, services rendered, caregiver and other-person presence or absence, prior-goal progress, and new goals.30 days
Substitution documentation when applicable: If hours support caregiver employment, exact dates and times worked throughout the prior approval period must be documented. Documentation supporting caregiver substitution and qualifying skilled services must be updated every three months.

RN versus LPN level of care

The requested nurse type must match the complexity of the member's condition and services.

Appropriate licensed nurse

RN level: RN services are appropriate when the complexity of the services or member's condition requires RN judgment, knowledge, and skills and the services cannot be performed by an LPN or delegated to a lesser-skilled individual.
LPN level: LPN services are appropriate when the complexity of the services or member's condition requires LPN judgment, knowledge, and skills, does not require RN skills, and cannot be delegated to a lesser-skilled individual.

Exclusions

Private duty nursing is not covered when ANY of the following exclusions applies.

Coverage exclusions

Facility setting: The member is in a hospital, residential treatment center, intermediate care facility for individuals with intellectual disabilities, or a residence or facility where nursing services are included by regulation or statute.
Noncovered service relationship: Services are unrelated to the plan of care, duplicate or supplant caregiver or other program services, are available through third-party liability coverage, or are respite care.
Adult member: The member is age 21 or older.Age 21 or older

Private duty nursing is not covered for members age 21 and older.

Private duty nursing is not covered when the member is in an institutional or residential setting, including a hospital, residential treatment center, intermediate care facility for individuals with intellectual disabilities, or another residence or facility where nursing services are included by regulation or statute.

Private duty nursing is not covered when services are unrelated to the member’s plan of care, duplicate or supplant care provided by the primary caregiver or another program or benefit, are available through third-party liability coverage, or constitute respite care.

Ongoing 24-hour-per-day, 7-day-per-week private duty nursing is not authorized. A short-term authorization of up to 24 hours per day may be approved for a maximum of one week to support caregiver adjustment and confirm that equipment is functioning properly.

Care is not medically necessary when it is requested solely for the convenience or preference of the primary caregiver or member.

The requested services must require the judgment, knowledge, and skills of the requested licensed nurse. Services are not covered when they can be provided solely by the primary caregiver, performed by a lower-skilled individual, or delegated to a lower-skilled person; the requested RN or LPN level must match the complexity of the member’s condition and care.

Authorization Limits and Service Parameters

Routine weekly authorization

Weekly nursing limitUp to 40 hours per week

Commuting timeUp to 2 hours round trip per day

Commuting daysUp to 5 days per week, dependent on documentation

Short-term intensive authorization

Daily nursing limitUp to 24 hours per day

Maximum durationNo more than 1 week

Permitted purposeShort-term caregiver adjustment and ensuring all equipment is functioning properly

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Obtain prior authorization before providing private duty nursing care. Approval is required for both new and continuing requests, with the applicable practitioner orders and clinical documentation submitted for review.

Documentation Required

New Request Clinical Documentation

For a new request, submit a treating practitioner order written within 30 days of the anticipated start date and medical notes documenting the need for private duty nursing as part of the treatment plan. The notes must be no older than 30 days from the anticipated start date.

Treating practitioner order: within 30 days before the anticipated start of service.
Clinical notes: no older than 30 days before the anticipated start of service.

Policy Background

Private duty nursing is skilled nursing provided on an hourly basis in the member’s home, rather than on a per-visit basis. Services are delivered by a registered nurse (RN) or licensed practical nurse (LPN) and are intended for medically necessary care requiring the applicable nurse’s judgment and skills, including caregiver teaching and supervision.

Key Definitions

Private Duty Nursing Care

Provider typeRegistered nurse or licensed practical nurse

Place of serviceThe member's own home

Service basisSkilled nursing services supplied on an hourly basis, not on a per-visit basis

Primary Caregiver

Who may serve as caregiverParent, guardian, other family member, or other typical caregiver

Primary responsibilityPrimarily responsible for the member's day-to-day care

Caregiver roleThe typical caregiver responsible for ongoing daily care of the member

Policy Summary

PayerMedStar Family Choice Maryland

PolicyPrivate Duty Nursing Care

Policy CodePolicy 1426

Change TypeAdministrative clarificationno material clinical or coverage change

Effective DateJuly 1, 2026

Last ReviewJul 1, 2025

Next Review DateNot specified

Key ActionObtain prior authorization for both new and continuing private duty nursing requests, with the required current orders and clinical documentation.

SourceLink

On This Page

Overnight awake-and-alert care

Overnight nursing limitUp to 8 hours per night

Weekly frequencyUp to 7 nights per week

Clinical basisMedically necessary awake-and-alert care, such as for tracheostomy, ventilator care, or another high-risk condition during sleep time

Employment or school coverage

Daily nursing limitUp to 10 hours per day

Weekly frequencyUp to 5 days per week

Schedule adjustmentAdjusted to documented work or class times and commute time

Documentation Required

Employment or Self-Employment Proof

When nursing substitutes for a primary caregiver’s employment, submit documentation establishing the caregiver’s job, schedule, dates, work location, and employer contact information. Self-employed caregivers must provide at least three qualifying business or financial records.

Employee documentation must be on company letterhead and include job title, dates and hours worked, work location, and employer contact information.
Self-employed caregivers must submit at least three qualifying records, such as tax documents, recent invoices, governmental business records, insurance documents, profit-and-loss or ledger records, or business bank statements.

Documentation Required

School Enrollment Proof

For substitution related to schooling, submit documentation from the educational institution or program confirming enrollment in a qualifying course of study and providing the exact course schedule.

Qualifying education includes a GED, high school diploma, associate’s degree, or first-time bachelor’s degree program.
Documentation must include the exact dates, times, and location of each course.

Documentation Required

Renewal Clinical Documentation

For renewal, submit treating practitioner documentation no older than 60 days before the anticipated renewal date confirming that private duty nursing remains medically necessary. The submission must include an updated plan of care and a practitioner order written within 60 days of renewal.

Continuing-need documentation: no older than 60 days before renewal.
Include an updated treating practitioner plan of care and order.

Documentation Required

Renewal Nursing Records

Submit complete and comprehensive nursing documentation from services provided during the 30 days before anticipated renewal to demonstrate continuing need.

Include notes from every prior date of service, time in and time out, and a thorough description of services rendered.
Document the presence or absence of primary caregivers and other adults or children during each visit.
Include prior-period goals and progress, plus a new nursing plan of care with goals for the requested timeframe.

Documentation Required

Prior-Period Employment Verification

When continued hours are requested for caregiver employment, verify the caregiver’s exact dates and times worked throughout the entire previous approval period. The proof must establish the job and work location, and pay stubs may be requested.

Use company letterhead and include job title, dates and hours worked, work location, and employer contact information.
Verification must cover the entire prior approval period.

Documentation Required

Three-Month Substitution Documentation

For caregiver-substitution services, provide new or updated documentation supporting the substitution circumstances and required skilled services every three months.

Update documentation supporting employment, schooling, caregiver sleep, or other applicable substitution circumstances.
Update documentation for the skilled services required under the applicable substitution circumstances.

Denial Risk

Adult Member Exclusion

Private duty nursing is not a covered benefit for members age 21 and older.

Denial Risk

No Available Primary Caregiver

A new request will not be approved unless at least one caregiver is willing and able to accept responsibility for the member’s care when the nurse is unavailable.

If no willing and able primary caregiver is available, private duty nursing will not be approved.

Denial Risk

Convenience or Lack of Qualifying Need

Do not request or approve private duty nursing solely for the convenience or preference of the member or primary caregiver. The primary caregiver must be unable to provide the required care because of a qualifying skill, continuous-alert-care, employment, or schooling circumstance.

Services are not covered when the primary caregiver can provide the care without a qualifying need for nursing substitution.
The request must address medically necessary care and any required skilled services.

Denial Risk

Institutional or Included Services

Private duty nursing is not covered in hospitals, residential treatment centers, intermediate care facilities for individuals with intellectual disabilities, or residences or facilities where nursing services are included by regulation or statute.

Do not cover services in an institutional setting where nursing is included in the living arrangement.
Apply the exclusion when nursing is included under applicable regulation or statute.

Denial Risk

Duplicative, Unrelated, or Respite Care

Private duty nursing is not covered when services are unrelated to the plan of care, duplicate or supplant care or other available benefits, or constitute excluded respite care.

Exclude services duplicating or replacing care provided by the primary caregiver or another insurance, entitlement, privilege, or program.
Exclude services for which the member has third-party liability coverage.
Respite care is not covered.

Billing Rule

24/7 Limitation

Do not authorize ongoing private duty nursing 24 hours per day, 7 days per week. A short-term 24-hour schedule may be authorized for a maximum of one week to support caregiver adjustment and equipment function.

After the short-term period, apply the applicable limits, including up to 10 hours per day and 5 days per week for qualifying employment or school needs, or up to 8 overnight hours when medically necessary.
Working and school-related hours must be supported by documented schedules and commute time; authorization may be up to 40 hours per week plus documented travel time up to 2 hours round trip per day for 5 days per week.
Medically necessary overnight care may be approved for up to 8 hours per night, 7 nights per week.

Denial Risk

Transportation Is Not Nursing Care

A private duty nurse should not transport a member to a routine medical appointment in place of the parent or guardian; that service is transportation, not nursing care.

The nurse may accompany the parent or guardian and member when the appointment occurs during currently authorized nursing hours.

Denial Risk

Nurse Skill Level Must Be Justified

Requested nursing services must require the judgment, knowledge, and skills of the requested RN or LPN based on the complexity of the services or the member’s condition. Services that can be performed by a lower-skilled provider or delegated to a lesser-skilled individual do not support the requested nurse level.

RN services must require RN-level skills and cannot be performed by an LPN or delegated to a lesser-skilled individual.
LPN services must require LPN-level skills, must not require RN-level skills, and cannot be delegated to a lesser-skilled individual.

Treating Practitioner

Eligible practitioner typesMD, DO, APRN, or PA

Practitioner roleTreating or managing the conditions that qualify the member for private duty nursing care

Hospital-originating requestsFor a new request originating from a hospitalization, the hospital practitioner may be considered the treating practitioner