CurrentTexas Children's Health PlanPolicy 11219

Prescribed Pediatric Extended Care Center (PPECC)

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Prior authorization, medical necessity, documentation, service limits, continued authorization, revisions, provider changes, and termination or denial of PPECC services for eligible Texas Children's Health Plan Medicaid members in Texas.

Policy Summary

PayerTexas Children's Health Plan

PolicyPrescribed Pediatric Extended Care Center (PPECC)

Policy CodePolicy 11219

Change TypeNo material change

Effective DateNovember 18, 2022

Next Review DateNot scheduled

Key ActionObtain prior authorization for all PPECC services except PPECC transportation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤20 yearsMaximum member age

≤12 hoursDaily service limit

90 daysInitial authorization

180 daysRecertification authorization

90 days

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CurrentTexas Children's Health PlanPolicy 11219

Prescribed Pediatric Extended Care Center (PPECC)

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Policy Summary

PayerTexas Children's Health Plan

PolicyPrescribed Pediatric Extended Care Center (PPECC)

Policy CodePolicy 11219

Change TypeNo material change

Effective DateNovember 18, 2022

Next Review DateNot scheduled

Key ActionObtain prior authorization for all PPECC services except PPECC transportation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤20 yearsMaximum member age

≤12 hoursDaily service limit

90 daysInitial authorization

180 daysRecertification authorization

90 days

RequiredPrior authorization

PPECC Coverage Criteria

Basic eligibility

PPECC services may be covered when all eligibility and medical necessity requirements are met.

Eligibility and admission requirements: The member must be eligible for THSteps-CCP; be 20 years of age or younger; be medically or technologically dependent; have an acute or chronic condition; require ongoing skilled nursing care beyond the level normally authorized through Medicaid home health skilled nursing and home health aide services; meet PPECC medical necessity and physician-prescription requirements; and choose PPECC services.Age <= 20 years

The member must be stable for outpatient services and must not present significant risk to other members or PPECC personnel.

Clinical medical necessity

Medical necessity requires all of the following clinical conditions.

Medical necessity: The member requires ongoing skilled nursing care and supervision, skilled observation, judgment, and therapeutic intervention for all or part of the day to correct or ameliorate health status; requires ongoing and frequent skilled interventions; and delayed intervention is expected to cause deterioration of a chronic condition, loss of function, imminent risk to health because of medical fragility, or risk of death.Ongoing and frequent skilled intervention

The requested level of service must be individualized, consistent with the diagnosis or symptoms, within accepted professional standards, safely deliverable, and not primarily for convenience.

Setting and physician requirements

The member must satisfy all setting and physician-order requirements.

Order, stability, and residence: The member must have a qualifying physician order, be stable for outpatient medical services, reside with a responsible adult, and not reside in a 24-hour inpatient facility such as a general acute hospital, skilled nursing facility, intermediate care facility, or special care facility.Physician order within 30 calendar days before admission

Admission must be voluntary and based on the member's or responsible adult's preference for PPECC services in place of private duty nursing.

Covered service limits

Covered PPECC services must satisfy all service limitations and coordination requirements.

Service delivery requirements: Services must be included in a PPECC plan of care, limited to no more than 12 hours in a 24-hour period, not provided overnight, and coordinated with the member's existing physicians, therapists, respiratory practitioners, home health agencies, hospice, and other medically necessary service providers.<= 12 hours per 24-hour period; no overnight services

When PPECC duplicates private duty nursing, PPECC hours must be a one-to-one replacement unless additional hours are medically necessary.

PPECC services are an alternative to private duty nursing (PDN) and, when they duplicate PDN, must generally replace PDN hours on a one-to-one basis unless additional hours are medically necessary. PPECC services do not eliminate the member’s right to medically necessary PDN, personal care services, home health skilled nursing, home health aide services, therapies, certified respiratory care practitioner services, or ECI services provided in the member’s residence.

Therapy and other services may be provided at a PPECC but are not included in PPECC coverage and must be billed separately by Medicaid-enrolled providers. Separately covered services include speech, physical, and occupational therapies; certified respiratory care practitioner services; ECI services; DME; medical supplies; nutritional products; home-based nursing and aide services; services that are the responsibility of a local school district; and individualized comprehensive case management beyond required service coordination. PPECC providers must coordinate these services with the member’s existing providers.

PPECC services are not approved when their sole purpose is to train or educate the member or responsible adult, including instruction on total parenteral nutrition (TPN) administration or chronic-condition management. Services primarily intended to provide respite care or child care, or provided solely for responsible-adult training, are also not covered.

PPECC services must be individualized, specific, and consistent with the member’s symptoms or confirmed diagnosis; they may not exceed the member’s needs. Services must meet generally accepted professional medical standards, may not be experimental or investigational, must be safely and effectively furnished, and may not be provided primarily for the convenience of the member, responsible adult, or provider.

PPECC is not medically necessary when the member’s needs can be met through part-time or intermittent visiting home health nursing or aide services available through Medicaid. Requests may also be denied when services duplicate other authorized services or the member does not meet the definition of a medically or technologically dependent minor.

Authorization, Documentation, and Denial Risks

Prior Authorization

PPECC Prior Authorization Required

Prior authorization is required for all PPECC services, except PPECC transportation. Requests must be based on the member’s current medical needs and submitted with the documentation required by the applicable initial, recertification, or revision process.

PPECC transportation is excluded from the prior authorization requirement.
Submit requests based on the member’s current medical needs and applicable medical-necessity documentation.
Initial, recertification, and revision requests may be authorized in hours per day, hours per week, or days per week.
When a request is submitted with verbal approval of the plan of care (POC), the ordering physician must sign the POC within 14 calendar days after the claims administrator receives the request; otherwise, the request is incomplete and will be denied.
For requests submitted with verbal POC approval, all other required forms must be signed and dated within 30 calendar days before the start-of-care (SOC) date.

Prior Authorization

Initial and Recertification Duration

PPECC Program Overview

Prescribed Pediatric Extended Care Center (PPECC) services are intended for medically or technologically dependent members age 20 or younger who require ongoing skilled nursing care, frequent skilled interventions, or routine use of medical technology to maintain life-sustaining function. Services are delivered in a licensed, non-residential center as an alternative to private duty nursing hours while preserving access to other medically necessary home and community services. The member must be stable for outpatient care and must not pose a significant safety risk to other members or PPECC personnel.

Key Terms

Prescribed Pediatric Extended Care Center (PPECC)

Facility settingServices are provided in a non-residential facility licensed by HHSC.

Eligible populationPPECCs serve four or more medically dependent or technologically dependent members who are 20 years of age or younger.

Skilled nursing requirementMembers require ongoing skilled nursing prescribed by the member’s physician to avert death or further disability.

Medical technology requirementMembers may instead require routine use of a medical device to compensate for a deficit in a life-sustaining body function.

Medically or technologically dependent member

DefinitionA medically or technologically dependent member requires ongoing skilled nursing care or is medically or technologically dependent because of a medically significant condition.

Admission Requirements

PPECC licensed non-residential facility

Admission to a PPECC licensed non-residential facility requires all of the following.

PPECC admission: The member is THSteps-CCP eligible, age 20 or younger, medically or technologically dependent, requires ongoing and frequent skilled nursing interventions beyond ordinary home health nursing or aide services, is stable for outpatient care, does not pose significant risk to others, has a qualifying physician order, resides with a responsible adult, and voluntarily chooses PPECC services.Age <= 20 years; physician order within 30 calendar days before admission

The member may not reside in a 24-hour inpatient facility.

Continued Authorization Requirements

PPECC licensed non-residential facility

Continued PPECC stay requires all of the following.

Continued PPECC stay: The member continues to meet medical necessity, requires ongoing skilled nursing and frequent skilled interventions, and has a current plan of care supported by an updated nursing assessment and required physician, PPECC RN, and member or responsible-adult signatures. The member, responsible adult, physician, and PPECC provider must agree in writing that recertification is appropriate.Recertification up to 180 calendar days

The provider must notify the claims administrator and ordering physician when the member's condition or service needs change and must request a revision when additional hours are medically necessary.

Discharge Requirements

PPECC authorization terminates when the member is no longer THSteps-CCP eligible, no longer meets PPECC medical necessity criteria, or the PPECC setting cannot ensure the member’s health and safety. Termination may also occur when the member or responsible adult refuses necessary compliance with the service plan, when the member changes providers and the required written notification and new-provider authorization request are submitted, or when the member elects to stop PPECC and receive ongoing services at home. In the latter circumstance, the home health agency or independent provider must submit or update the required authorization documentation.

Service and Authorization Limits

PPECC daily service limit

Daily service limitPPECC services are limited to no more than 12 hours in a 24-hour period.

Overnight servicesPPECC services may not be provided overnight.

Plan of carePPECC services must be included in a PPECC plan of care.

Initial authorization duration

Authorization typeInitial authorization requests are subject to the initial authorization limit.

Maximum durationInitial requests may be prior authorized for a maximum of 90 calendar days.

Assessment timing

Policy Summary

PayerTexas Children's Health Plan

PolicyPrescribed Pediatric Extended Care Center (PPECC)

Policy CodePolicy 11219

Change TypeNo material change

Effective DateNovember 18, 2022

Next Review DateNot scheduled

Key ActionObtain prior authorization for all PPECC services except PPECC transportation.

SourceLink

On This Page

Initial PPECC authorization may be approved for no more than 90 calendar days. Each recertification is a new authorization period and may be approved for up to 180 calendar days when medical-necessity criteria are met.

Initial requests: maximum 90 calendar days.
Recertification requests: maximum 180 calendar days.
The member or responsible adult, physician, and PPECC provider must agree in writing that recertification is appropriate for each certification period.
A provider change during an existing authorization period is authorized for no more than 90 calendar days, regardless of the number of provider changes.

Documentation Required

Authorization Units and Current Signatures

Authorization requests may specify services as hours per day, hours per week, or days per week. Required signatures must be current and timely; signature dates after the SOC date can invalidate coverage for dates before the latest signature.

Initial, recertification, and revision requests may use hours per day, hours per week, or days per week.
The ordering physician, PPECC RN, and member or responsible adult must sign the applicable initial, recertification, and revised request forms.
If a signature is dated after the SOC date, dates of service before the latest dated signature will be denied.
For verbal POC approvals, the physician’s POC signature is due within 14 calendar days after receipt of the request; other required forms must be signed within 30 calendar days before SOC.

Documentation Required

Medical Necessity Documentation

Document that the member meets all PPECC admission and medical-necessity requirements. The record must establish eligibility, age, the need for ongoing skilled nursing, medical or technological dependence, and the member’s ability to receive stable outpatient care safely.

Eligible for THSteps-CCP and 20 years of age or younger.
Requires ongoing and frequent skilled nursing interventions and supervision; delayed intervention is expected to risk deterioration, loss of function, imminent health risk, or death.
Is medically or technologically dependent under Texas Health and Safety Code Chapter 248A.
Is stable for outpatient services and does not pose a significant risk to other members or PPECC personnel.
Document that needs exceed intermittent or part-time services and require ongoing skilled nursing care.

Documentation Required

Ordering Physician Examination and Order

Obtain a PPECC order signed and dated by an ordering physician who personally examined the member and reviewed the appropriate medical records. The order must be issued within 30 calendar days before admission and be in place by the SOC when required by the request type.

The physician may waive the examination only when the diagnosis is established, the member remains under the physician’s continuing care and supervision, and the physician states in writing that an examination within 30 calendar days before admission is not medically necessary.
After a waiver, the physician must examine the member in person within 365 calendar days after the last examination; the physician and PPECC must retain waiver documentation.
The order must be signed and dated by the ordering physician and included in the required request documentation.

Documentation Required

Consent and Service Choice

Admission must be voluntary and based on the member’s or responsible adult’s preference for PPECC services instead of private duty nursing. Obtain signed, dated consent and the required acknowledgment and information-sharing authorization.

Consent must document the member’s or responsible adult’s choice of PPECC services.
The consent must acknowledge that private duty nursing or other services might be reduced as a result of accepting PPECC services.
Obtain consent to share the member’s personal health information with other providers as needed for care coordination.
The member must reside with the responsible adult and not in a 24-hour inpatient facility.

Documentation Required

Initial Nursing Assessment

A PPECC RN must complete the initial comprehensive nursing assessment no earlier than 3 business days before SOC and no later than the day of admission. The assessment cannot be delegated and must establish the POC and support the need for ongoing skilled nursing.

Address care complexity and intensity, condition stability and predictability, and frequency of skilled nursing needs.
Identify medical, nursing, psychosocial, therapeutic, nutritional, dietary, functional, educational, developmental, and training needs and goals.
Describe wounds, equipment needs, and whether the setting can safely accommodate, maintain, and clean required devices, equipment, and supplies.
Document the responsible adult’s comprehension, receptivity to training, and ability level.

Documentation Required

Initial Request Packet

Submit a complete initial request packet by the applicable deadline, with all forms signed and dated as required. The packet must include the request, POC, consent, nursing addendum, physician order, and transportation-related determinations and staffing when applicable.

Completed CCP Prior Authorization Request form signed and dated by the ordering physician, in place by SOC.
Completed PPECC POC signed and dated by the ordering physician and PPECC RN completing the POC.
Indication of whether the member is stable enough for PPECC transportation; if stable, specify whether an RN, LVN, or direct care staff member must accompany the member.
Signed and dated consent documenting the choice of PPECC services, acknowledgment regarding possible reduction of private duty nursing, and consent to share information for coordination of care.
Completed Nursing Addendum to Plan of Care for Private Duty Nursing and/or PPECCs, signed by the ordering physician, assessing RN, and member or responsible adult, including the updated problem list, rationale and summary, contingency plan, 24-hour care flow sheet, physician/member acknowledgment, PPECC order, and required transportation staff determination.

Documentation Required

Revision Documentation

When the member’s condition or authorized hours change during an authorization period, submit a revision request supported by a PPECC RN reassessment when the condition has changed. The revised request must include updated forms and all required signatures.

A PPECC provider may request a revision at any time when authorized services are not commensurate with medical needs or additional ongoing skilled nursing hours are medically necessary.
Notify the claims administrator and ordering physician; submitting the revised request with physician signatures satisfies the notification requirement.
Complete CCP Prior Authorization Request form signed and dated by the ordering physician.
Submit an updated PPECC POC signed by the ordering physician, PPECC RN completing the POC, and member or responsible adult.
Submit a completed Nursing Addendum signed by the ordering physician, assessing RN, and member or responsible adult.

Documentation Required

Recertification Documentation

Recertification requires an updated assessment and a complete request packet supporting continued medical necessity. The updated PPECC RN assessment must be completed no more than 30 calendar days before the current authorization expires.

CCP Prior Authorization Request signed and dated by the ordering physician within 30 calendar days before SOC.
PPECC POC signed by the ordering physician, PPECC RN, and member or responsible adult within 30 calendar days before SOC; an alternate provider form is acceptable if it contains the initial-request elements.
Provider must ensure the ordering physician reviews and signs the POC within 30 calendar days before the authorization expires.
Nursing Addendum signed by the ordering physician, assessing RN, and member or responsible adult within 30 calendar days before SOC, including the updated 24-hour flow sheet and required updates when applicable.
Written physician order and signed, dated consent documenting PPECC choice, possible reduction of other services, and information-sharing consent.

Documentation Required

Provider Change Documentation

When services move to a new PPECC provider during an existing authorization period, the new provider must follow the initial-request process and submit a provider-change letter.

The member or responsible adult must sign and date a letter documenting the date services ended with the previous provider, the previous and new provider names, and the reason for the change.
The new provider must submit all documentation required for an initial request.
The new authorization may not exceed 90 calendar days, and provider changes do not extend the overall authorization limitations.

Denial Risk

Member or Medical Necessity Criteria Not Met

PPECC services may be denied or terminated when eligibility, physician, age, medical-dependence, or medical-necessity requirements are not met. Authorization may also terminate when the setting cannot ensure safety or the member does not participate as required.

Member is not eligible for THSteps-CCP, is older than 20, or is not medically or technologically dependent.
Member does not have an ordering physician or does not meet PPECC medical-necessity or ongoing skilled-nursing criteria.
Member’s needs can be met through part-time or intermittent Medicaid home health nursing or aide services.
The place of service cannot ensure the member’s health and safety.
Member or responsible adult refuses to comply with the service plan when compliance is necessary for health and safety.
The member changes providers without the required written notification and new-provider request, or declines PPECC services in favor of home-based services.

Denial Risk

Noncovered Purpose, Duplication, or Incomplete Request

Requests are not approvable when PPECC is sought for a noncovered purpose, duplicates services, or is incomplete or untimely. Ensure the submission is consistent, complete, and supports ongoing skilled nursing services.

Sole purpose is respite care, child care, or training and education of the member or responsible adult.
Request is incomplete, late, missing required documentation, or contains inconsistent information.
Requested services are not ongoing skilled nursing services.
There is a duplication of services or the member does not meet the definition of a medically or technologically dependent minor.

Denial Risk

Setting, Safety, or Participation Failure

PPECC services may be denied or terminated when the setting is excluded, cannot safely serve the member, or the member does not participate in the service plan. Confirm the member’s residence, stability, safety, and cooperation before submitting.

Member resides in a 24-hour inpatient facility, including a general acute hospital, skilled nursing facility, intermediate care facility, or special care facility or sub-acute AIDS-treatment unit.
Member is not stable for outpatient medical services or presents a significant risk to other members or PPECC personnel.
PPECC setting cannot accommodate or safely maintain the member’s medical equipment, devices, or supplies.
Member or responsible adult refuses to comply with the service plan when compliance is necessary to protect health and safety.
Member or responsible adult does not participate sufficiently for required care, training, or coordination.

Denial Risk

Separately Covered or Duplicative Services

Services separately covered by Texas Medicaid or duplicative of other covered services are not payable as PPECC services. Review the full plan of care and coordinate benefits before requesting authorization.

Speech, occupational, physical, and respiratory therapy, and early childhood intervention services.
Durable medical equipment, medical supplies, and nutritional products provided through Medicaid DME or medical-supply providers.
Private duty nursing, skilled nursing, or home health aide services provided in the home when medically needed in addition to authorized PPECC services.
Services that are the legal responsibility of a local school district.
Individualized comprehensive case management beyond required service coordination.
Any other service duplication identified in the request or member’s current authorizations.

Denial Risk

Untimely or Invalid Signatures

Signature timing directly affects authorization validity. Requests with late, missing, or invalid signatures may be denied for dates before the latest valid signature or denied as incomplete.

Ordering physician, PPECC RN, and member or responsible adult signatures must be current on initial, recertification, and revised requests.
Signatures on required forms must generally be dated within 30 calendar days before SOC; signatures dated after SOC do not support prior dates of service.
For verbal POC approval, the physician must sign the POC within 14 calendar days after the claims administrator receives the request.
Recertification request, POC, and nursing addendum signatures must meet the specified 30-calendar-day timing requirements, and the physician order must be in place by SOC.

Required level of careThe member requires ongoing skilled nursing care beyond the level of skilled nursing and home health aide services normally authorized under Texas Medicaid Home Health services.

Qualifying medical technologyThe member may require routine use of medical technology to compensate for a deficit in a life-sustaining body function.

Excluded minor conditionsMinor or occasional conditions that do not require continuous nursing care, including asthma, diabetes, or a condition requiring an epinephrine injection, do not satisfy the definition.

The initial comprehensive nursing assessment must be completed no earlier than 3 business days before the start of care and no later than the day of admission.

Recertification authorization duration

Authorization typeA recertification is a new authorization period.

Maximum durationA recertification may be approved for up to a maximum of 180 calendar days.

Medical necessityRecertification may be approved when the member meets medical necessity criteria.