CurrentUnitedHealthcarePolicy CS102NM.C

Private Duty Nursing Services (for New Mexico Only)

Defines coverage criteria and coding guidance for Private Duty Nursing (PDN) services with skilled care for UnitedHealthcare Community Plan members in New Mexico. Applies to providers requesting PDN under state contract and Medicaid requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPrivate Duty Nursing Services (for New Mexico Only)

Policy CodePolicy CS102NM.C

Change TypeRoutine reviewno coverage changes

Effective DateSep 1, 2025

Next Review Date

Key ActionDocument requests using Home Health Certification (CMS-485) with a physician or authorized advanced practitioner signature and use InterQual LOC Private Duty Nursing assessment to determine PDN hours.

SourceLink

POLICY UPDATE CHANGES

Removed reference link to the Medical Policy titled Home Hemodialysis (for New Mexico Only) (retired Apr. 1, 2026).

Routine review; no change to coverage guidelines and previous policy version archived (CS102NM.B).

1state-specific policy

InterQualPDN hours tool

CMS-485required form

8procedure codes

Coverage Criteria for Private Duty Nursing

Policy Summary

PayerUnitedHealthcare

PolicyPrivate Duty Nursing Services (for New Mexico Only)

Policy CodePolicy CS102NM.C

Change TypeRoutine reviewno coverage changes

Effective DateSep 1, 2025

Next Review Date

SourceLink

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Covered when Skilled Care and documentation criteria met

Covered when ALL of the following are met:

Skilled Care Established: Private Duty Nursing services with Skilled Care are covered when the service meets the federal, state, and contractual definition of Skilled Care.

Refer to New Mexico Managed Care Policy Manual, Chapter 8 and applicable federal/state definitions.

Documentation: Request documented using Home Health Certification (CMS-485) including a plan of care signed by an M.D., D.O., or an advanced practitioner (NP, CNS, PA) in accordance with applicable law and regulation.

CMS-485 must include the plan of care and required signature(s).

PDN Hours Determination: Number of Private Duty Nursing hours determined using InterQual LOC: Home Care Q & A, Private Duty Nursing (PDN) Assessment.

Follow InterQual criteria to establish hours/level of care.

The list of procedure codes in this policy is provided for reference only. Listing a code does not by itself indicate that the service is a covered or non‑covered benefit; actual coverage and payment are determined by applicable federal, state, and contractual requirements and laws. The inclusion of a code does not guarantee reimbursement or claim payment, and other policies or guidelines may apply.

Services that do not meet the definition of Skilled Care or that lack required documentation and signatures are not covered and may be denied. Requests must meet federal, state, and contractual definitions of Skilled Care and include required supporting documentation; absence of these elements can result in claim denial or non‑coverage.

Specifically, listing a procedure code in this policy does not establish coverage when the clinical criteria or documentation requirements are not met.

Procedure Codes and PDN Hours Determination

Applicable Private Duty Nursing Procedure CodesHCPCS

T1000	Private duty/independent nursing service(s), licensed, up to 15 minutes.
S9123	Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used).
S9124	Nursing care, in the home; by licensed practical nurse, per hour.
T1001	Nursing assessment/evaluation.
T1002	RN services, up to 15 minutes.
T1003	LPN/LVN services, up to 15 minutes.
T1030	Nursing care, in the home, by registered nurse, per diem.
T1031	Nursing care, in the home, by licensed practical nurse, per diem.

PDN hours determination

PDN hours determinationNumber of Private Duty Nursing hours is determined using InterQual LOC: Home Care Q & A, Private Duty Nursing (PDN) Assessment.

Reference for coverageOnce Skilled Care coverage is established, InterQual LOC guides hours/level of care determination.

Applicable guidanceFollow federal, state, and contractual requirements when using InterQual assessment for PDN hours.

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Private Duty Nursing (PDN) with Skilled Care is covered only when federal, state, and contractual requirements are met and the services meet the definition of Skilled Care. Prior authorization is required when applicable; providers must ensure Skilled Care is clearly established in the documentation to support coverage.

Refer to InterQual LOC: Home Care Q&A, Private Duty Nursing (PDN) Assessment for guidance on number of PDN hours.
Prior authorization may be required per contract and state regulations.

Documentation Required

Required Documentation

Requests must be documented using the Home Health Certification (CMS-485). The CMS-485 must include a plan of care signed by a physician (M.D. or D.O.) or, where permitted by law, an advanced practice provider (NP, CNS, or PA). Ensure the CMS-485 and signed plan of care are current and fully complete before submission.

CMS-485 (Home Health Certification) with physician or authorized advanced practitioner signature is required.
Include the InterQual PDN Assessment supporting the number of PDN hours requested.

Denial Risk

Documentation / Skilled Care Not Established

If Skilled Care or a completed CMS-485 with an appropriately signed plan of care is not provided, the request does not establish medical necessity and is at high risk for denial. Providers should confirm Skilled Care needs are clearly documented (clinical skilled nursing tasks, frequency, and medical justification) and include all supporting records with the authorization request to avoid delays or denials.

Absence of Skilled Care documentation or missing/unsigned CMS-485 may result in denial of PDN coverage.
Ensure clinical justification describes specific skilled nursing services, frequency, and clinical rationale.

Note

Provider Responsibilities

Providers are responsible for submitting complete documentation and obtaining any required prior authorization. Verify state or contract-specific requirements (including New Mexico Managed Care Policy Manual Chapter 8) and include InterQual assessment results and the CMS-485 so coverage and number of PDN hours can be determined.

Confirm prior authorization requirements per payer contract and state rules.
Include CMS-485, signed plan of care, and InterQual PDN Assessment with requests.

Key Definitions

Private Duty Nursing (PDN)

DefinitionPrivate Duty Nursing: Provision of continuous Skilled Care from Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) under the direction of the member's physician (CFR § 440.80).

Care settingProvided in the home as continuous skilled nursing under physician direction.

LicensureServices delivered by RNs or LPNs per applicable licensure requirements.

Skilled Care

DefinitionSkilled Care: A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care (CMS Glossary).

Functional roleRequires skilled nursing or rehabilitation staff for management, observation, and evaluation of care.

Coverage implicationServices must meet Skilled Care definition to qualify for PDN coverage under federal/state/contractual rules.

Skilled Nursing Care

DefinitionSkilled Nursing Care: A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse) (CMS Glossary).

ScopeEncompasses tasks that require the training and licensure of an RN or LPN to perform safely and correctly.

Relation to PDNSkilled Nursing Care components must be present for PDN services to be covered as Skilled Care.

Background

Private Duty Nursing (PDN) refers to the provision of continuous Skilled Care by Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) under the direction of the member’s physician (CFR § 440.80). PDN is intended to provide ongoing, skilled nursing services that can only be performed safely and correctly by a licensed nurse and must meet federal, state, and contractual definitions of Skilled Care.

When PDN is requested, the service is covered only if Skilled Care is established and the request is supported by required documentation. The number of PDN hours is determined using the InterQual® LOC: Home Care Q & A, Private Duty Nursing (PDN) Assessment. Requests should be documented using the Home Health Certification (CMS‑485) including a plan of care signed by an MD or DO, or by an authorized advanced practitioner as permitted by law.

Providers must follow applicable federal and state rules and the New Mexico Managed Care Policy Manual (Chapter 8) when requesting PDN; failure to meet these requirements or to provide the CMS‑485 with the appropriate signatures may result in denial.