CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Private Duty Nursing (PDN) — Coverage Criteria

Governs coverage, medical necessity, and prior authorization requirements for Private Duty Nursing (PDN) provided in home settings to Neighborhood Health Plan of Rhode Island members across listed lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrivate Duty Nursing (PDN) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests using Neighborhood's prior authorization forms on the provider website.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>= 2 hrs/dayMin skilled nursing need

60 daysPlan-of-care renewal

T1001–T1003PDN billing codes

HBE, MED, CSN, SUB, RHP, RHE, MMPCovered lines

Coverage Criteria for Private Duty Nursing (PDN)

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PDN medical necessity

Plan of care: There is a physician‑approved written plan of care with short and long‑term goals specified that is renewed at least every sixty (60) days60 days
Home safety: The member can be safely maintained in the home in the absence of nursing care
The caregiver(s) must be able to safely care for the member in the absence of the home health agency
Skill requirement: The member's condition requires continuous skilled care greater than two (2) hours per day that can only be conducted by an RN or LPN according to practice standards>2 hours/day
Scope of practice: Services provided are reasonable and necessary to care for the member's condition and are in accordance with the scope of practice of a licensed nurse
InterQual: Medical necessity criteria must be met within the InterQual® Level of Care: Home Care Q&A: Private Duty Nursing (PDN) AssessmentInterQual LOC
InterQual used to determine range of PDN hours

Assessments

Regulatory nursing assessments and reassessments are covered when meeting regulatory requirements:

Regulatory assessments: Assessment at admission and reassessments per regulatory scheduleevery 60 days or with condition change or after inpatient admission

Includes assessment at admission, reassessment every sixty (60) days, with changes in condition, or with resumption of care after an inpatient admission

Excluded from coverage are members who are residents of institutional settings: nursing facilities, hospitals, or licensed residential care facilities. Services that are not provided in a home setting are also not covered. Respite, companionship, general supervision, infant/child sitting, age‑appropriate childcare to support caregivers, meal services, homemaking, heavy cleaning or household repair performed solely for caregiver convenience or to allow a caregiver to work or attend school are excluded. Lack of an available caregiver does not convert an otherwise unskilled service into a skilled service.

Coverage does not apply when the member is not present in the home, when services are provided to anyone other than the member (for example family members or other residents), or when PDN duplicates or overlaps other services. Certain items and services are explicitly excluded from this benefit, including drugs and biologics, services covered under End‑Stage Renal Disease programs, prosthetic devices, respiratory care services, and dietary/nutritional personnel when not incidental to the plan of care.

Private Duty Nursing will not be authorized when the required care is custodial in nature or can safely be provided by a lower‑level professional (for example, a certified nursing assistant). Services that are primarily respite, companionship, general supervision, homemaking, meal preparation, or other non‑skilled supports are considered custodial and are not eligible for PDN authorization.

PDN must be delivered and billed as one‑on‑one care; when duplication or overlap of services exists, Neighborhood may authorize the lowest level of care needed to safely meet the member's needs rather than PDN.

Billing Codes and Coding Rules

Covered HCPCS CodesHCPCSCovered

T1002	RN services, up to 15 minutes.
T1003	LPN/LVN services, up to 15 minutes.
T1001	Nursing assessment/evaluation, per diem

Covered CPT/HCPCS CodesmixedCovered

T1002	RN services, up to 15 minutes.
T1003	LPN/LVN services, up to 15 minutes.
T1001	Nursing assessment/evaluation, per diem

inv-06: Minimum skilled nursing need

Minimum skilled nursing needMember's condition requires continuous skilled care greater than two (2) hours per day

Who must provide careCare must be provided by an RN or LPN according to practice standards

PurposeIntended for members with complex medical conditions or disabilities managed at home

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required for PDN

Prior authorization and medical review are required for Private Duty Nursing (PDN). Providers must submit authorization requests using Neighborhood's prior authorization process.

Use Neighborhood's prior authorization forms and process at www.nhpri.org (Providers > Provider Resources > Forms).
Phone assistance: 1-800-963-1001.

Note

Consider Home Health Aide Long Term Care

Home Health Aide Long Term Care may be considered as an alternative for members with complex medical conditions to support the plan of care when there are no skilled needs.

Documentation Required

Physician-Approved Plan of Care and Required Assessments

There must be a physician-approved written plan of care with short- and long-term goals specified that is renewed at least every sixty (60) days. Regulatory nursing assessments and re-assessments are required on admission, at least every sixty (60) days, with changes in condition, and with resumption of care after an inpatient admission.

Physician's order and physician-approved written plan of care renewed at least every 60 days.
Regulatory assessments: on admission, every 60 days, with condition changes, and after inpatient admission.

Denial Risk

Exclusions — Non‑Covered Situations

Services are not covered when the member is a resident of a nursing facility, hospital, or licensed residential care facility; when services are not provided in a home setting; when services are custodial in nature or can be provided by a lower-level professional (e.g., CNA); when the member is not present in the home; or when services are provided to anyone other than the member. Respite, companionship, general supervision, homemaking, meal services, and similar non-skilled activities are not covered.

Not covered if member resides in a nursing facility, hospital, or licensed residential care facility.
Not covered if not provided in a home setting.
Not covered when services are custodial, non-skilled, or can be provided by a CNA.
Not covered when member is not present in the home.
Not covered when services are provided to others besides the member.
Non-covered services include respite, companionship, general supervision, homemaking, meal services, heavy cleaning, household repair, and services solely for caregiver convenience.

Background on Private Duty Nursing

Private Duty Nursing (PDN) is defined as continuous, individualized skilled nursing provided in the home for members with complex medical conditions who require ongoing skilled nursing beyond routine intermittent visits. PDN supports maintaining the member in their residence rather than institutional care and is intended for situations in which the member’s condition requires nursing skill that can only be provided by a licensed RN or LPN.

To meet the clinical context for PDN, services typically exceed the threshold of greater than two (2) hours per day of continuous skilled nursing and must be reasonable and necessary within the licensed nurse’s scope of practice. InterQual® Level of Care guidance is used to determine the clinically appropriate range of PDN hours and to confirm medical necessity.

Key Definitions

inv-12: Home setting

DefinitionAny non-institutional residence where the member has established their place of residence for the time period when home care services are being provided (own dwelling, apartment, home of friend/family, group home, homeless shelter, temporary residence, or community setting)

ExclusionsHospitals, skilled nursing facilities, intermediate care facilities for the developmentally disabled, or any other institutional facility providing medical, nursing, rehabilitative, or related care are not considered a home setting

Non-qualifying settingsDay care settings, adult day care, or adult medical care do not meet the definition of a home setting

inv-13: Skilled Care

DefinitionA service that must be provided by a registered nurse or licensed practical nurse (under RN supervision) in order to be safe and effective

Not skilledA service is not considered skilled merely because performed by or under supervision of a licensed nurse; if it can be safely performed by the average nonmedical person without direct supervision, it is not skilled

Scope noteSkilled determination depends on safety and effectiveness when performed by an RN or LPN per practice standards