Home Health Policy 710 — Services to Children (PDN interaction)
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Defines Montana Medicaid coverage rules for home health services provided to children (under 21), requires consideration of private duty nursing (PDN) first, documents when Home Health may be used if PDN is unavailable, prior authorization requirements for PDN, and non-reimbursement for oversight/case management.
No material clinical or coverage changes in this revision.
Coverage criteria: Home Health and Private Duty Nursing (PDN)
Home Health vs PDN coverage criteria
Coverage rules regarding Home Health and PDN for children:
Based on federal Medicaid definition; services are not provided solely for parental convenience.
When the member qualifies for PDN and a PDN provider is available, Home Health services are not available.
If PDN services become available, the Home Health agency must transfer the case to the PDN agency; the department may review such cases.
Authorization is mandatory for PDN coverage.
Services provided by a Home Health agency solely to oversee a Private Duty Nursing (PDN) provider or to provide case management are not reimbursable. This activity is considered a duplicate service and would be denied. Bill only for allowable, direct skilled nursing services; do not submit claims for oversight or case management functions performed by a Home Health agency when those functions duplicate PDN responsibilities.
Home Health services are not available to children who qualify for PDN. PDN is considered equally safe and effective and less costly than Home Health; therefore, when a child qualifies for PDN, PDN should be used instead of Home Health.
Home Health may be provided to a child only if a PDN provider is not available. The Home Health agency must document in the member’s chart that PDN services were not available. If PDN services later become available, the Home Health agency must transfer the case to the PDN agency; such cases may be reviewed by the department. Additionally, providing Home Health solely to oversee PDN or to perform case management remains not reimbursable.
Provider actions, authorization, and documentation requirements
PDN requires prior authorization by MPQH
All private duty nursing (PDN) services require prior authorization by the Mountain Pacific Quality Health Foundation (MPQH); authorization is determined based on the severity of the task and the time required to perform the skilled nursing task. Providers must obtain MPQH authorization before billing or providing PDN services.
PDN preferred before Home Health for children
PDN must be considered before initiating Home Health for children; Home Health services are not available to children who qualify for PDN because PDN is considered equally safe and effective and less costly. Provide PDN when the member qualifies and a PDN provider is available.
Document PDN unavailability and transfer when available
If a PDN provider is not available, the home health agency must document in the member's chart that PDN services were not available. If PDN services become available, the Home Health agency must transfer the case to the PDN agency; the department may review such cases.
- Document in the member's chart that PDN services were not available before providing Home Health.
- Transfer the case to a PDN agency immediately when PDN becomes available; expect possible departmental review.
No reimbursement for oversight or case management of PDN
Services provided by a Home Health agency solely to oversee the PDN provider or to provide case management are not reimbursable and will be denied as duplicate services.
- Do not bill Home Health for oversight or case management of PDN.
- Such oversight/case management is considered a duplicate service and is not payable.
Background and policy context
Under federal Medicaid law, a child is an individual who has not reached their 21st birthday. Montana Medicaid covers Private Duty Nursing (PDN) for non‑institutionalized children who require complex skilled nursing care. PDN must be considered before initiating Home Health services because PDN is judged to be equally safe and effective and less costly; all PDN services require prior authorization by the Mountain Pacific Quality Health Foundation (MPQH) (authorization is based on task severity and time required).
Definitions
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