CurrentOklahoma Health Care AuthorityPolicy 317:30-5-550

Paid Family Caregiver (PFC) Services

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Guidelines for Oklahoma SoonerCare and SoonerSelect coverage, authorization, provider qualifications, caregiver requirements, billing, and service limits for Paid Family Caregiver services for children ages 0 through 20 approved for private duty nursing.

Policy Summary

PayerOklahoma Health Care Authority

PolicyPaid Family Caregiver (PFC) Services

Policy CodePolicy N/A

Change TypeRevision of Existing Criteria

Effective DateMarch 1, 2026

Next Review DateSeptember 1, 2026

Key ActionSubmit prior authorization for PFC services billed under T1004 before initiating services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

0–20Eligible child age range

40/weekMaximum combined PFC and PDN hours

80 hoursMinimum caregiver training

160/weekExample maximum PFC units

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CurrentOklahoma Health Care AuthorityPolicy 317:30-5-550

Paid Family Caregiver (PFC) Services

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Sign up for Oklahoma Health Care Authority Policy 317:30-5-550 alerts

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Policy Summary

PayerOklahoma Health Care Authority

PolicyPaid Family Caregiver (PFC) Services

Policy CodePolicy N/A

Change TypeRevision of Existing Criteria

Effective DateMarch 1, 2026

Next Review DateSeptember 1, 2026

Key ActionSubmit prior authorization for PFC services billed under T1004 before initiating services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

0–20Eligible child age range

40/weekMaximum combined PFC and PDN hours

80 hoursMinimum caregiver training

160/weekExample maximum PFC units

Example combined unit maximum

T1004Covered code requiring prior authorization

Program Background

The Paid Family Caregiver (PFC) program supports children with complex special health care needs who qualify for in-home private duty nursing and need a community-based alternative to institutional care. Under home health agency oversight, a trained family caregiver may provide eligible care in place of nursing services, helping maintain access to in-home care when nursing staffing is unstable.

Key Definitions

Family member

Eligible relationshipsChild, parent, parent-in-law, sibling, grandparent, grandchild, or spouse

Other family relationshipAny other individual related by blood

Qualifying individualAny other individual with a close association equivalent to a family relationship

Complex caregiver

RoleA person trained for complex care who provides services to eligible patients

Typical relationshipOften a family member

Required supervisionWorks through a home care agency under the direction and supervision of a Registered Nurse or Licensed Practical Nurse

Paid Family Caregiver (PFC)

Service optionAllows a trained family caregiver to provide eligible care for qualifying children

Relationship to nursing servicesCare may be provided in lieu of nursing services

Weekly limitUp to 40 hours per week, concurrent with—not in addition to—authorized private duty nursing hours

Eligibility and Coverage Requirements

Member Eligibility

PFC is intended for children who meet all of the following eligibility conditions:

Member eligibility: The member is a child age 0 through 20, is approved for private duty nursing services, has complex special health care needs, and qualifies for in-home nursing as part of the SoonerCare PDN benefit package.Age 0–20; approved for PDN

PFC is provided as a community-based alternative to institutional care.

Eligible Home Health Agency

The servicing home health agency must meet all of the following requirements:

Agency requirements: The agency has a full OHCA provider contract, is licensed by the Oklahoma State Department of Health as a home care agency, and complies with general home health agency rules under OAC 317:30-5-545.All three agency conditions required

Billing Codes and Service Limits

Covered PFC Code Requiring Prior AuthorizationHCPCSCovered

T1004

Nursing aide service, up to 15 minutes per unit

Referenced PFC and PDN Combined Billing CodesHCPCS

T1000	Private duty nursing code referenced for combined PFC and PDN authorization; full description is not stated in the document
T1004	Nursing aide service, up to 15 minutes per unit

PFC weekly service limit

Maximum PFC hoursUp to 40 hours per week

Shared hoursThe 40 hours include authorized private duty nursing hours

Additional hoursPFC hours are not added on top of private duty nursing hours

Complex caregiver training

Minimum trainingAt least 80 hours

Competency requirementPass a competency evaluation

Covered topics

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required for T1004

Submit the prior authorization request for T1004 using the applicable group code. Modifiers are not required on the PA request, but claims must continue to use the appropriate CPT code and modifiers.

T1004 — Nursing aide service, up to 15 minutes per unit

Prior Authorization

Complete Authorization Before Initiation

Complete all required service-authorization and prior-authorization steps before initiating paid family caregiver (PFC) services. PFC services may begin only after the steps required under OAC 317:30-5-559 and the applicable prior-authorization requirements under OAC 317:30-5-560.1 are completed.

Policy Summary

PayerOklahoma Health Care Authority

PolicyPaid Family Caregiver (PFC) Services

Policy CodePolicy N/A

Change TypeRevision of Existing Criteria

Effective DateMarch 1, 2026

Next Review DateSeptember 1, 2026

Key ActionSubmit prior authorization for PFC services billed under T1004 before initiating services.

SourceLink

On This Page

The general home health agency rules generally require Medicare certification.

Complex Caregiver Qualifications

The complex caregiver must meet all of the following requirements:

Caregiver qualifications: The caregiver is at least 18 years old, passes criminal and abuse registry background checks, and provides care through the home care agency under the direction and supervision of an RN or LPN.Age 18 or older; required background checks passed

The caregiver is employed by the agency as the complex caregiver.

Caregiver Training

The complex caregiver must complete all of the following training and competency requirements:

Training and competency: The complex caregiver completes at least 80 hours of training and passes a competency evaluation covering agency new-employee orientation, communication with the care team, documentation, safety care, medications, respiratory care, neurological care, nutrition, genitourinary care, integumentary care, and social determinants of health.At least 80 training hours plus competency evaluation

The listed topics are included in the curriculum but are not necessarily exhaustive.

Combined PFC and PDN Limits

Authorized PFC and PDN services must remain within a shared weekly limit:

Weekly service and billing limit: PFC hours are limited to 40 hours per week and are authorized concurrent with, not in addition to, PDN hours. The combined PFC and PDN billing may not exceed the applicable maximum units for the week.Maximum 40 combined hours per week

The document provides an example of 160 PFC units plus 288 PDN units, for a combined maximum of 448 units in the week.

PFC does not cover care provided during long absences from the home that are unrelated to medical treatment or required medical care, including family vacations.

The complex caregiver may not drive the patient's vehicle during transport.

The coverage limitations in OAC 317:30-5-558 apply to all PFC services.

Includes orientation, care-team communication, documentation, safety care, medications, respiratory care, neurological care, nutrition, genitourinary care, integumentary care, and social determinants of health

PFC units

Service codeT1004

Example PFC units160 units per week

Equivalent service time40 hours per week

PDN units in example

Service codeT1000

Service typePrivate duty nursing

Example maximum288 units per week

Combined PFC and PDN units

Combined weekly maximum448 units per week

PFC component160 T1004 units

PDN component288 T1000 units

Billing Rule

Coordinate PFC and PDN Authorizations

Coordinate PFC and private duty nursing (PDN) authorizations because the services operate within a shared weekly maximum. PFC hours authorized by OHCA and/or SoonerSelect are concurrent with, not in addition to, authorized PDN hours.

PFC may total up to 40 hours per week.
PFC and PDN authorizations must be managed together when preparing the treatment and authorization requests.

Documentation Required

Maintain the Treatment Plan and Caregiver Credentials

Maintain a treatment plan that meets OAC 317:30-5-560 requirements and incorporate it into the PFC treatment-plan request. Keep documentation of the caregiver’s credentials and all other records required under OAC 317:30-5-560.2.

Treatment plan requirements apply to each member receiving PFC services.
Caregiver credential records must be maintained with the PFC documentation.

Documentation Required

Document Training and Competency

Document that the complex caregiver completed at least 80 hours of training and passed the required competency evaluation. Maintain records covering required areas such as agency orientation, care-team communication, documentation, safety, medications, respiratory, neurological, nutrition, genitourinary, integumentary, and social-determinants-of-health care.

Retain evidence of completed training hours.
Retain the successful competency-evaluation record.

Documentation Required

Submit the Comprehensive Medical Record

Submit the comprehensive medical record when OHCA or the applicable authorization process requests supporting documentation. Supplier-generated forms and physician letters of medical necessity do not substitute for the complete medical record.

Do not rely on a supplier form or physician letter in place of the comprehensive medical record.

Denial Risk

Agency Qualification Failure

Payment may be denied unless the home health agency is qualified to provide PFC services. The agency must hold a full OHCA contract, be licensed by the Oklahoma State Department of Health as a home care agency, and comply with applicable home health agency requirements, including OAC 317:30-5-545.

Full OHCA provider contract required.
OSDH home care agency license required.
Applicable home health rules must be met, generally including Medicare certification.

Denial Risk

Caregiver Qualification Failure

Payment may be denied if the employed complex caregiver does not meet required qualifications. The caregiver must be at least 18 years old and pass criminal and abuse-registry background checks, in addition to completing required training and competency requirements.

Minimum age: 18 years.
Criminal and abuse-registry background checks must be passed.

Denial Risk

Do Not Omit Nursing Supervision

Ensure the complex caregiver provides services through a home care agency under the direction and supervision of a Registered Nurse (RN) or Licensed Practical Nurse (LPN), as required by the Oklahoma Nursing Practice Act.

Caregiver supervision must be provided through the agency.
RN or LPN direction and supervision is required.

Billing Rule

Do Not Exceed the Combined Weekly Limit

Keep billing within the combined PFC and PDN weekly maximum. PFC is concurrent with, rather than additive to, PDN; claims must not exceed the maximum units allowed between the two codes.

Combined maximum: 40 hours per week, or 448 units in the stated example.
Example allocation: 160 PFC units plus up to 288 PDN units, for 448 combined units.
When the same provider bills both services, the weekly claim cannot exceed the applicable combined maximum.

Denial Risk

Restricted Activities and Absences

Apply the PFC service restrictions when scheduling and billing care. The complex caregiver may not drive the patient’s vehicle during transport, and PFC does not pay for care during extended nonmedical absences from the home, such as family vacations.

No driving the patient’s vehicle during transport.
Long absences unrelated to medical treatment or required medical care are not covered.

Denial Risk

Insufficient Supporting Records

Prior authorization does not guarantee approval. Be prepared to provide additional supporting documentation, and submit a complete record because insufficient or substitute documentation may not support authorization or payment.

Additional documentation may be required after or during the authorization process.
Prior authorization alone is not a guarantee of payment or approval.