CurrentUnitedHealthcarePolicy CS328KY.07

Prescribed Pediatric Extended Care (for Kentucky Only)

Policy governs medical necessity and coverage/authorization requirements for Prescribed Pediatric Extended Care centers for UnitedHealthcare members in Kentucky.

Policy Summary

PayerUnitedHealthcare

PolicyPrescribed Pediatric Extended Care (for Kentucky Only)

Policy CodePolicy CS328KY.07

Change TypeRoutine review (no material changes)

Effective DateJul 1, 2025

Next Review Date

Key ActionObtain and renew authorization every 6 months and assign/document an appropriate Level of Care using the PPEC Leveling Evaluation Tool prior to admission.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines.

Archived previous policy version CS328KY.06.

6 mosauthorization renewal interval

4levels of care

T1025,T1026listed billing codes

KYapplicable state

Coverage and Medical Necessity

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing Codes, Modifiers, and Leveling

Covered HCPCS/T codes referencedHCPCSCovered

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

Level of care modifiers/indicatorsmixed

TT	Level of Care = Individualized service provided to more than one patient in same setting
TF	Level of Care = Intermediate level of care
TG	Level of Care = Complex/high tech level of care

PPEC Leveling Evaluation Tool score ranges — Levels 1–4

Level 112–16 points (Mild Acuity)

Level 217–32 points (Moderate Acuity)

Level 333–48 points (Moderate to Maximal Acuity)

Level 449+ points (Maximal Acuity)

Authorization, Documentation, and Reauthorization

Prior Authorization

Prior Authorization and Level of Care Requirement

Prior authorization is required prior to admission. An appropriate Level of Care must be assigned and documented using the PPEC Leveling Evaluation Tool prior to admission. Authorization must be renewed every 6 months.

Assign and document Level of Care with the PPEC Leveling Evaluation Tool before admission.
Authorization required and subject to 6-month renewal intervals.

Note

Provider Action: Remaining Provider Requirements

Providers must submit the full reauthorization packet described below when requesting a 6-month renewal; failure to provide required documentation may result in denial of the renewal request.

Submit all required reauthorization documents at time of renewal request.
Ensure documents are complete and dated as specified to avoid processing delays.

Documentation Required

Reauthorization Documentation Requirements (6-month renewals)

Requests for renewal of services require submission of all of the following: a reevaluation by the member's primary care provider (PCP) performed within 30 days of the reauthorization request; an updated recommendation from the PCP; an updated consent form signed by the parent or legal guardian and witnessed prior to admission to the PPEC center; an updated Provision of Services with appropriate supporting documentation; and documentation of the member's Level of Care.

PCP reevaluation completed within 30 days of the reauthorization request.
Updated PCP recommendation.
Updated, witnessed consent form signed by parent or legal guardian prior to admission.
Updated Provision of Services with supporting documentation.
Documentation of the member's Level of Care (per PPEC Leveling Evaluation Tool).

Note

Level of Care and Definitions

An appropriate Level of Care must be assigned using the Prescribed Pediatric Extended Care (PPEC) Leveling Evaluation Tool prior to admission and documented in the member's record. The Leveling Tool is available to providers upon request. Levels: Level 1 (mild acuity) = 12–16 points; Level 2 (moderate acuity) = 17–32 points; Level 3 (moderate to maximal acuity) = 33–48 points; Level 4 (maximal acuity) = 49+ points.

Use the PPEC Leveling Evaluation Tool to assign Level of Care prior to admission.
Tool availability: providers may request the Leveling Tool from the payer or program administrator.

Denial Risk

Missing Reauthorization Documentation — Denial Risk

If required reauthorization documentation is not submitted or is incomplete (for example, missing PCP reevaluation within 30 days, missing updated PCP recommendation, unsigned or unwitnessed consent, missing Provision of Services, or missing Level of Care documentation), the renewal request may be delayed or denied. Providers should ensure all items in the reauthorization packet are provided to avoid denial risk.

Incomplete or missing reauthorization documents may result in denial or delay of authorization renewal.
Confirm PCP reevaluation date, signatures, and Level of Care documentation are included with the renewal request.

Policy Background

Prescribed Pediatric Extended Care (PPEC) centers provide intensive, extended multidisciplinary services for children with complex medical, physical, mental, and psychosocial impairments who are medically or technologically dependent as defined under Kentucky law. These centers deliver part-day basic and skilled services and serve children who require continuous therapeutic interventions or skilled nursing supervision prescribed by a licensed physician.

An appropriate Level of Care must be assigned using the PPEC Leveling Evaluation Tool prior to admission. The tool stratifies acuity into four levels: Level 1: 12–16 points, Level 2: 17–32 points, Level 3: 33–48 points, and Level 4: 49+ points. Documentation should reference the statutory definitions for a medically/technologically dependent child and for a PPEC per Kentucky regulation.

Coverage and medical necessity determinations for PPEC services in Kentucky defer to the state regulatory criteria in KAR 902, Chapter 020, Regulation 280; providers must meet those criteria and follow the policy's authorization and documentation requirements.

Key Definitions

Medically/Technologically Dependent Child (definition)

TermMedically/Technologically Dependent Child

DefinitionA child who because of a medical condition requires continuous therapeutic interventions or skilled-nursing supervision which must be prescribed by a licensed physician and administered by, or under the direct supervision of, a licensed registered nurse (KRS 216.875).

PPECC (Prescribed Pediatric Extended Care Center) definition

TermPPECC (Prescribed Pediatric Extended Care Center)

DefinitionAny building or other place that provides, for part of the day, basic services to three or more Medically Dependent or Technologically Dependent Children who are not related to the owner or operator, as defined in KRS 216.875.

OpenPayer