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Private Duty Nursing Services (for New Jersey Only)
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Defines coverage, eligibility, and state-specific requirements for Private Duty Nursing (PDN) services for UnitedHealthcare Community Plan members in New Jersey, including criteria for EPSDT, MLTSS, and DDD Supports Plus PDN programs.
Medical records documentation language was added clarifying that benefit coverage is determined by federal, state, or contractual requirements and that documentation may be required to assess medical necessity.
Medical records documentation used for reviews: added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required to assess clinical criteria for coverage.
Added requirements that the patient's medical record must contain documentation that fully supports medical necessity and that documentation should be legible, maintained, and available upon request.
Coverage Criteria for Private Duty Nursing (PDN)
Medical necessity criteria
Covered when criteria below are met according to state regulations and program enrollment (EPSDT, MLTSS, or SPPDN):
N.J.A.C. § 10:60-5.4.e; N.J.A.C. § 10:60-5.8.a
N.J.A.C. § 10:60-5.3
N.J.A.C. § 10:60-5.8
N.J.A.C. § 10:60-5.4.b
N.J.A.C. § 10:60-5.9.d
N.J.A.C. §§ 10:60-5.4.c; 10:60-5.5.d; 10:60-5.9.f
Services that alone do not establish the need for Private Duty Nursing (PDN) include observation, monitoring, recording, or assessment of the patient; occasional suctioning; uncomplicated gastrostomy feedings (i.e., feedings that are not complicated by frequent regurgitation or aspiration); and seizure disorders that are controlled with medication or that consist of frequent minor seizures not occurring in clusters or associated with status epilepticus. These services, without the Skilled Nursing Interventions identified in the medical necessity criteria, are not sufficient to justify PDN.
PDN does not include provision of respite or supervision and is not intended to substitute for routine parenting tasks. Coverage is for skilled, continuous nursing care as defined by the policy and state regulations, not for relief of caregivers or non-skilled household supervision.
No additional exclusion details are specified in this portion of the policy.
State regulations (N.J.A.C.) specify that Private Duty Nursing Services provided solely for attendance at school or other activities when not needed in the home are not covered. Under MLTSS, PDN is limited to a maximum of 16 hours per 24‑hour period (this total includes services provided or paid for by other sources), and there must be a live‑in primary adult caregiver who accepts 24‑hour responsibility for the beneficiary's health and welfare unless PDN is solely for IV therapy. These provisions reflect N.J.A.C. §§ 10:60‑5.9.a, 10:60‑5.9.b, and 10:60‑5.9.c as applied in this policy.
Coding and Limits
| 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. |
| T1000 | Private duty/independent nursing service(s) - licensed, up to 15 minutes. |
| 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. |
Provider Requirements and Actions
Document prior authorization on CMS-485 with signed plan of care
Prior authorization requests must be documented using the Home Health Certification (CMS-485), which includes a plan of care signed by a physician (M.D. or D.O.) or signed by an advanced practitioner (NP, CNS, or PA) in accordance with applicable law and regulation. Applicable procedure codes listed in the policy are provided for reference.
- Use CMS-485 as the authorization document.
- Include plan of care signed by an authorized clinician (physician or qualified advanced practitioner).
- Include any applicable procedure codes as listed in the policy for reference.
Follow governing federal, state, or contractual requirements
When determining coverage or processing prior authorization requests, reference and follow applicable federal, state, or contractual requirements when they differ from the standard benefit plan; those requirements govern in the event of a conflict.
- Check federal, state, or contractual benefit plan terms before applying this policy.
- In case of conflict, federal, state, or contractual requirements supersede the standard benefit plan guidance in this policy.
Provide complete, legible supporting documentation with requests
Include all required supporting documentation with requests and ensure medical records are complete, legible, maintained in the patient record, and available upon request to support medical necessity determinations.
- Provide relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
- Ensure documentation is legible and retained in the patient’s medical record.
- Make records available upon request to support review and authorization.
Step therapy: none specified
No step therapy requirements are specified in this portion of the policy.
Use Home Health Certification (CMS-485) with signed plan of care
Requests should be documented using the Home Health Certification (CMS-485) including a plan of care signed by a physician or authorized advanced practitioner; include documentation elements that fully support medical necessity.
- CMS-485 with signed plan of care is required for requests.
- Documentation should include relevant medical history, physical exam, and pertinent diagnostic test results to support medical necessity.
Ensure medical record fully supports medical necessity
The patient’s medical record must contain documentation that fully supports the medical necessity for the requested PDN services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Documentation should demonstrate how the requested services meet clinical criteria.
- Maintain records in the patient chart and make them available upon request for review.
Denial risk: insufficient documentation may lead to denial
Lack of medical record documentation that fully supports medical necessity may result in denial or non-coverage of requested services.
Denial risk: unavailability or illegibility of records jeopardizes coverage
Failure to provide medical records documentation that fully supports medical necessity — and that is legible and available upon request — may jeopardize coverage determinations and result in denial.
- Maintain legible records and ensure they are accessible upon request to avoid coverage jeopardy.
- Provide requested records promptly during review.
Background
Private Duty Nursing (PDN) provides continuous, individual nursing care in the home for beneficiaries whose severity of illness requires complex Skilled Nursing Interventions on a continuous basis. PDN is intended to deliver ongoing, high‑acuity nursing services—such as care for individuals dependent on mechanical ventilation, with an active tracheostomy requiring deep suctioning, or otherwise requiring continuous skilled interventions—rather than intermittent or observation‑level care. Coverage eligibility is determined in accordance with applicable state regulations and program enrollment (EPSDT, MLTSS, or DDD Supports Plus PDN).
Definitions
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