RetiredUnitedHealthcarePolicy CS381LA.A

Pediatric Day Health Care (for Louisiana Only)

Defines Louisiana Medicaid coverage criteria, documentation, certification, and service limits for Pediatric Day Health Care for beneficiaries from birth up to 21 years who require ongoing skilled nursing and therapeutic interventions in a PDHC setting.

Policy Summary

PayerUnitedHealthcare

PolicyPediatric Day Health Care (for Louisiana Only)

Policy CodePolicy CS381LA.A

Change TypeRetired (operational disenrollment)

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization with the standardized PA form, physician orders/POC, checklist, and face‑to‑face evaluation; authorizations certified for periods not to exceed 90 days.

SourceLink

POLICY UPDATE CHANGES

Policy retired and Louisiana plan membership disenrolled on Apr. 1, 2026.

New Medical Policy effective 09/01/2025 introduced PDHC coverage criteria for Louisiana Medicaid.

0-21eligible beneficiary age range

≤90initial certification (max days)

Up to 12service hours/day

7 days/weekpossible frequency

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Coverage Criteria for Pediatric Day Health Care (PDHC)

Initial PDHC Coverage Criteria

Covered when ALL of the following are met

PDHC eligibility criteria: Be Louisiana Medicaid eligible; be from birth up to 21 years of age; have a medically complex condition involving one or more physiological or organ systems requiring ongoing skilled nursing care and therapeutic interventions performed by a knowledgeable or experienced RN or LPN to preserve/maintain health, prevent death, treat/cure disease, ameliorate disabilities or other adverse health conditions, and/or prolong life; be a candidate for outpatient medical services in a home or community-based setting; have a signed physician's order and individualized plan of care (POC) specifying frequency and duration and clearly outlining the skilled nursing care and therapeutic interventions to be performed in the PDHC facility and not in excess of the beneficiary's needs.

Services may be provided up to 12 hours per day and 7 days per week as documented in the POC.

Recertification / Renewal Criteria

Renewal/recertification requirements (time-based)

Certification and renewal: Initial prior authorization shall be certified for a period not to exceed 90 days. Re-evaluation of PDHC services must be performed at a minimum every 90 days; documentation must include review of the current POC, documentation of current assessment and progress toward goals, a face-to-face evaluation between the prescribing physician and beneficiary every 90 days (physician may extend the face-to-face interval to 180 days in exceptional circumstances), a completed PA form, and a completed PA checklist indicating the beneficiary's skilled nursing care needs.90 days

Physician discretion can extend the face-to-face evaluation interval to 180 days in exceptional circumstances.

The PDHC per diem does not cover items or services that are outside the scope of medically skilled care provided in the Pediatric Day Health Care setting. Specifically, education and training services, before and after school care, respite services, and child care due to work or other parental time constraints are not included in the PDHC per diem. Also excluded are medical equipment, supplies, and appliances, parenteral or enteral nutrition, and infant food or formula.

Note: The policy further states that PDHC does not provide respite care and is not intended to serve as an auxiliary or back-up for respite care.

Use of PDHC for non-medical custodial needs or services typically provided in educational settings is not covered. In particular, billing PDHC for respite, routine child care, educational services, or services that should be provided in school settings is not covered under the PDHC per diem and may result in non-coverage or denial.

Procedure and Billing Codes

Applicable procedure codes (reference)HCPCS

T1025	Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, mental and psychosocial impairments, per diem.
T1026	Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, mental, and psychosocial impairments, per hour.
T2002	Non-emergency transportation; per diem

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required; Certification Period and Renewal

Prior authorization is required. Use the standardized Prior Authorization form and submit physician orders/plan of care, PA checklist, and evidence of face-to-face evaluations as specified. The prior authorized case shall be certified for a period not to exceed 90 days; re-evaluation and renewal are required at least every 90 days (face-to-face may be extended to 180 days in exceptional circumstances at the ordering physician's discretion).

Standardized Prior Authorization Form explaining why services cannot be provided elsewhere (including the school system).
Physician's most recent note documenting medical necessity for PDHC.
Physician's order and plan of care (POC) for PDHC.
Prior Authorization checklist indicating the beneficiary's skilled nursing care requirements.
Face-to-face evaluation between prescribing physician and beneficiary every 90 days (may be extended to 180 days in exceptional circumstances).
Certification period: up to 90 days per authorization; renewals require re-evaluation at least every 90 days.

Background on Pediatric Day Health Care (PDHC)

Pediatric Day Health Care (PDHC) is intended to deliver medically skilled, multidisciplinary services to children and young adults with complex medical needs; it is not designed to substitute for respite or routine child care. The policy explicitly notes that PDHC does not provide respite care and is not intended as an auxiliary or back-up to respite services, underscoring that PDHC coverage is limited to medically necessary services documented in the plan of care rather than custodial, educational, or parental-work related child care.

Key Definitions

Medically complex condition

DefinitionA condition involving one or more physiological or organ systems that requires ongoing skilled nursing care and therapeutic interventions performed by a registered nurse (RN) or licensed practical nurse (LPN) to preserve or maintain health, prevent death, treat or cure disease, ameliorate disabilities or other adverse health conditions, and/or prolong life.

Required level of careRequires skilled nursing care and therapeutic interventions on an ongoing basis (not intermittent or solely custodial).

Clinical purposeServices aim to preserve/maintain health status, prevent death, treat/cure disease, ameliorate disabilities, or prolong life.

Setting implicationIndicates need for a higher level of care that cannot be provided in more integrated community settings and may require PDHC or long-term/in-home nursing alternatives.

Age applicabilityApplies to beneficiaries from birth up to 21 years of age when determining PDHC eligibility.