CurrentUnitedHealthcarePolicy CSNC.MP.017.08

Private Duty Nursing Services (for North Carolina Only)

This policy governs UnitedHealthcare coverage guidance for private duty nursing services for members in North Carolina and references state Medicaid clinical coverage criteria and InterQual guidance for clinical determinations. It applies to payor decisions and providers delivering private duty nursing in NC.

Policy Summary

PayerUnitedHealthcare

PolicyPrivate Duty Nursing Services (for North Carolina Only)

Policy CodePolicy CSNC.MP.017.08

Change TypeHCPCS code removals (11/01/2025)

Effective DateNov 1, 2025

Next Review Date

Key ActionVerify member benefits and any prior authorization requirements before providing private duty nursing services.

SourceLink

POLICY UPDATE CHANGES

Removed HCPCS codes S9123, S9124, and T1002 from Applicable Codes.

Removed reference link to the Medical Policy titled Home Hemodialysis (for North Carolina Only) (retired May 1, 2026).

Archived previous policy version CSNC.MP.017.07.

NCApplicable state

1CPT/HCPCS listed

InterQualReferenced guidance

2Referenced policies

Policy Summary

PayerUnitedHealthcare

PolicyPrivate Duty Nursing Services (for North Carolina Only)

Policy CodePolicy CSNC.MP.017.08

Change TypeHCPCS code removals (11/01/2025)

Effective DateNov 1, 2025

Next Review Date

Key ActionVerify member benefits and any prior authorization requirements before providing private duty nursing services.

SourceLink

On This Page

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Beneficiaries Age 21 and Older

Medical necessity clinical coverage for beneficiaries age 21 and older follows state Medicaid policy.

Age 21 and older medical necessity: Coverage and medical necessity criteria are determined by the North Carolina Medicaid Clinical Coverage Policy: Community-Based Services, 3G-1: Private Duty Nursing for Beneficiaries Age 21 and Older.

Refer to the referenced NC Medicaid policy for specific criteria

Beneficiaries Under 21 Years of Age

Medical necessity clinical coverage for beneficiaries under 21 follows state Medicaid policy and InterQual guidance.

Under 21 medical necessity: Coverage and medical necessity criteria are determined by the North Carolina Medicaid Clinical Coverage Policy: Community-Based Services, 3G-2: Private Duty Nursing for Beneficiaries Under 21 Years of Age, and InterQual LOC: Home Care Q&A Private Duty Nursing Assessment for determining hours.

Use InterQual as a guideline to determine private duty nursing (PDN) hours for beneficiaries under 21

The inclusion of a procedure or diagnosis code in this policy is for reference only and does not imply that the service described by the code is a covered health service or guarantees payment. Benefit coverage and reimbursement determination are governed by the member’s applicable federal, state, or contractual benefit documents and applicable laws, not by the presence of a code in this policy. Providers must verify coverage and payment eligibility through the member’s plan documents and any prior authorization processes.

This policy defers to the referenced North Carolina Medicaid clinical coverage policies for definitions of medical necessity and determinations of not medically necessary (NMN) conditions. For beneficiaries under age 21, InterQual LOC: Home Care Q&A Private Duty Nursing Assessment is referenced for determining the number of private duty nursing hours. See the cited NC Medicaid clinical coverage policies and InterQual guidance for explicit NMN criteria and operational definitions.

Applicable Codes and Coding Guidance

Applicable CPT/HCPCS Codes (reference)CPT

T1000

Private duty/independent nursing service(s) - licensed, up to 15 minutes.

Removed HCPCS Codes (11/01/2025)HCPCSNot Covered

S9123	Previously listed HCPCS code removed
S9124	Previously listed HCPCS code removed
T1002	Previously listed HCPCS code removed

InterQual PDN assessment

Assessment toolUse InterQual LOC: Home Care Q&A Private Duty Nursing (PDN) Assessment to determine the number of PDN hours for beneficiaries under 21.

Age applicabilityApplies only to beneficiaries under 21 years of age.

Reference policyFollow North Carolina Medicaid Clinical Coverage Policy: Community‑Based Services, 3G-2 for medical necessity criteria for under‑21 beneficiaries.

PurposeProvides guideline to quantify required private duty nursing hours rather than replace state clinical criteria.

Provider Actions and Billing Requirements

Prior Authorization

Prior Authorization and Benefit Verification

Providers must verify member benefits and prior authorization requirements with UnitedHealthcare before initiating Private Duty Nursing (PDN) services. Prior authorization may be required depending on the member's benefit plan, state mandates, and contract terms. Verification should include service coverage, required diagnosis or clinical documentation, benefit limits (hours or duration), and any applicable billing rules.

Check member benefit plan for PDN coverage and any medical necessity criteria
Obtain prior authorization when required by the member's plan before rendering services
Confirm authorized start/end dates, authorized units/hours, and frequency limits
Document clinical justification and retain prior authorization approval details for claims

Note

Alert: Providers should review any short actionable guidance or alerts specific to PDN from UnitedHealthcare and payer communications (e.g., updates, clinical edits, or temporary program changes) that may affect authorization or billing.

Note

Plan Requirements Precedence

Plan, state, and federal contractual requirements take precedence over this policy. When there is a conflict between this Medical Policy and the member's governing benefit documents (including state-mandated benefits or specific contract language), the federal, state, or contractual benefit plan requirements govern. Always check for and follow any applicable laws or contract provisions.

In case of conflict, follow the member's benefit plan, state mandate, or contract terms
Confirm any applicable mandatory coverage requirements before denying or modifying services

Note

Code Listing Disclaimer

Listing of a code in this policy is for reference only and does not guarantee coverage or payment. Benefit coverage and reimbursement are determined by the member's benefit plan, applicable laws, and contract terms. Providers must not assume inclusion of a code implies coverage and should verify coding and payment rules with the payer.

Code lists are informational — verify coverage and payment via benefit documents and prior authorization
Inclusion of a code does not imply a right to reimbursement or guarantee claim payment

Background

This policy applies specifically to private duty nursing services provided in North Carolina and relies on North Carolina Medicaid clinical coverage policies to define medical necessity by beneficiary age. For beneficiaries age 21 and older, medical necessity is determined by the NC Medicaid Clinical Coverage Policy: Community‑Based Services, 3G‑1: Private Duty Nursing for Beneficiaries Age 21 and Older. For beneficiaries under 21, medical necessity is determined by NC Medicaid Clinical Coverage Policy: Community‑Based Services, 3G‑2: Private Duty Nursing for Beneficiaries Under 21 Years of Age, with the InterQual LOC: Home Care Q&A Private Duty Nursing Assessment used to determine the number of PDN hours. Listing of codes (for example, T1000) in this policy is for reference only and does not itself authorize payment; benefit coverage is governed by applicable federal, state, and contractual requirements.

OpenPayer

Private Duty Nursing Services (for North Carolina Only)

Coverage Criteria — Private Duty Nursing (North Carolina)

Applicable Codes and Coding Guidance

Provider Actions and Billing Requirements

Background

Definitions