SECTION 363.311. Prior Authorization Requirements

(a) PDN services must be prior authorized. Prior authorization is a condition of reimbursement but is not a guarantee of payment.

(b) HHSC will publish in the Texas Medicaid Provider Procedures Manual and websites all processes, tools, and scales used to prior authorize PDN services. HHSC may use only these processes, tools, and scales to prior authorize PDN services.

(c) The provider must submit a complete request for prior authorization in order to be considered by HHSC for reimbursement. The authorization request must include the authorization form approved by HHSC, signed and dated by the recipient's treating physician. The provider must use the documents, tools, or processes published in the Texas Medicaid Provider Procedures Manual or any updates made available through bulletins, banners, or other means to request prior authorization.

(d) Documentation supporting the prior authorization request must clearly and consistently describe the recipient's:

(1) current diagnosis;

(2) functional status and condition;

(3) history and treatment; and

(4) frequency and complexity of skilled nursing needs, as those needs arise over the span of a 24-hour day.

(e) The supporting documentation:

(1) must include:

(A) documentation of the treating physician's orders, e.g., a prescription or a written or documented verbal order signed and dated by a treating physician; and

(B) a plan of care that satisfies the requirements as described in §363.313 of this subchapter (relating to Plan of Care);

(2) may include any additional materials the provider may choose to submit that supports the medical necessity of the requested PDN services;

(3) must explain to HHSC's satisfaction how the requested PDN is necessary to correct or ameliorate the recipient's disability or physical or mental illness or condition; and

(4) must show that the recipient's skilled nursing needs cannot be met on a part-time or intermittent basis by a visiting nurse as described in Chapter 354, Subchapter A, Division 3 of this title (relating to Medicaid Home Health Services).

(f) Process for authorizations.

(1) HHSC authorizes requested PDN services required to meet all of the recipient's PDN needs when the medical necessity for a private duty nurse is documented.

(2) HHSC reviews requests for PDN services that comply with subsections (b) through (e) of this section.

(3) The information must be complete and consistent throughout the documentation associated with the prior authorization request for PDN services.

(4) PDN services are prior authorized with reasonable promptness. Prior authorization determinations are completed by HHSC within three business days of receipt of a complete request.

(5) If a request for PDN is incomplete, inconsistent, or unclear, HHSC, its contractor, or MCO will contact the provider to request additional or clarifying documentation to enable HHSC to make a decision on the request.

(6) Prior authorizations for PDN services are not denied or reduced based solely on the recipient's diagnosis, type of illness, or health condition.

(7) Prior authorizations for PDN services are not denied or reduced solely because the recipient's condition or health status is stable or has not changed.

(g) HHSC authorizes requested medically necessary PDN services when:

(1) the prior authorization request for PDN is complete, as described in subsections (b) through (e) of this section;

(2) the requested services are nursing services as defined by the Texas Nursing Practice Act and its implementing regulations; and

(3) no third-party resource, as described in the Texas Medicaid Provider Procedures Manual, is financially responsible for the requested services.

(h) HHSC may deny or reduce PDN services when the:

(1) request is incomplete;

(2) information in the request is inconsistent;

(3) documentation does not explain to HHSC's satisfaction the medical need for a private duty nurse or no longer supports the medical need for a private duty nurse;

(4) documentation does not address how PDN services correct or ameliorate the recipient's disability or physical or mental illness or condition;

(5) requested PDN services are not nursing services as defined by the Texas Nursing Practice Act and its implementing regulations;

(6) medical director, after conferring with the recipient's treating physician, determines the requested PDN services are not medically necessary to correct or ameliorate the recipient's disability or physical or mental illness or condition; or

(7) recipient's nursing needs could be met through a visiting nurse as described in Chapter 354, Subchapter A, Division 3 of this title.

(i) Only the medical director may deny PDN services on the basis that the services do not correct or ameliorate the recipient's disability or physical or mental illness or condition. Before denying PDN services, the medical director will contact the recipient's treating physician to determine whether additional information or clarification can be provided that would allow for authorization of PDN services.

(j) All notices must afford a recipient an opportunity for a fair hearing in accordance with 42 CFR, Part 431, Subpart E, related to Fair Hearings for Applicants and Recipients.

(1) HHSC may determine, based on the information submitted, that PDN services will be denied, terminated, or reduced. A notice regarding the denial, termination, or reduction of PDN services must be sent to the recipient and the requesting provider. The notice must inform the recipient of his or her right to request a fair hearing as described in Chapter 357, Subchapter A of this title (relating to Uniform Fair Hearing Rules).

(2) When HHSC determines that the requested services are not PDN services and that the documentation may support authorization of personal care services, as described in Subchapter F of this chapter (relating to Personal Care Services), the denial notice:

(A) describes the basis for this determination;

(B) briefly describes the personal care services benefit; and

(C) explains how to request personal care services.

(3) When HHSC determines that documentation for the services requested does not support a request for PDN because the recipient does not need more individual and continuous nursing care than could be provided on a per-visit basis, as described in §354.1031 of this title (relating to General), the denial notice:

(A) describes the basis for this determination;

(B) briefly describes the home health nursing benefit; and

(C) explains how to request prior authorization for home health nursing.

(4) When HHSC determines that the request for PDN services is incomplete, as referenced in subsection (h)(1) of this section, the denial notice will inform the recipient that the documentation or information is incomplete and identify the sections of the documentation or information that are incomplete.

(5) When HHSC determines that the request for PDN services is inconsistent, as referenced in subsection (h)(2) of this section, the denial notice will inform the recipient that the documentation or information is inconsistent and identify the inconsistencies.

(6) When HHSC determines that the request for PDN services does not explain to HHSC's satisfaction the medical need for a private duty nurse or no longer supports the medical need for a private duty nurse as referenced in subsection (h)(3) of this section, the denial notice will inform the recipient and address how the documentation or information does not explain to HHSC's satisfaction the medical need for a private duty nurse or how the documentation no longer supports the medical need for a private duty nurse.

(7) When HHSC determines that the information provided does not address how PDN services correct or ameliorate the recipient's disability or physical or mental illness or condition as referenced in subsection (h)(4) of this section, the denial notice will inform the recipient and address how the information provided in the request does not support the medical need for PDN services.

(8) When HHSC determines that the requested PDN services are not nursing services as defined by the Texas Nursing Practice Act and its implementing regulations, as referenced in subsection (h)(5) of this section, the denial notice will inform the recipient and address how the requested PDN services are not nursing services as defined by the Texas Nursing Practice Act and its implementing regulations.

(9) When an HHSC medical director, after conferring with the recipient's treating physician, determines the requested PDN services are not medically necessary to correct or ameliorate the recipient's disability or physical or mental illness or condition, as referenced in subsection (h)(6) of this section, the denial notice will inform the recipient and address why the requested PDN services are not medically necessary to correct or ameliorate the recipient's disability or physical or mental illness or condition.

(10) When HHSC determines that the recipient's nursing needs could be provided by a visiting nurse through Home Health Skilled Nursing services, as referenced in subsection (h)(7) of this section, the denial notice for PDN services will describe the basis for the denial and explain how to request Home Health Skilled Nursing services.

(k) A provider's authorization for PDN services is terminated if the recipient is no longer eligible for EPSDT.

(l) HHSC may ask a provider to take on an existing authorization for PDN services if it becomes necessary to terminate another provider's authorization for PDN services because the:

(1) recipient's health and safety needs are in jeopardy; or

(2) PDN services provided are inconsistent with the plan of care submitted for authorization.

Source Note: The provisions of this §363.311 adopted to be effective October 15, 2015, 40 TexReg 7056