Timely Submission of PDN Prior Authorization Request for Additional Information

NC Medicaid authorizes Private Duty Nursing (PDN) services for Medicaid beneficiaries in compliance with Clinical Coverage Policies 3G-1, Private Duty Nursing for Beneficiaries Age 21 and older and 3G-2, Private Duty Nursing for Beneficiaries Under 21 Years of Age. As dictated by policy, there are required documents that a PDN agency must submit to Medicaid when requesting prior approval (PA) for PDN services. The required forms are located at https://medicaid.ncdhhs.gov/forms/private-duty-nursing-forms.

A PA request submitted to NCTracks with missing or incomplete required documents initiates a Request for Additional Information (RAI) notice to the submitting PDN agency, specifying the information necessary to complete the PA review. The documents requested are due to Medicaid no later than ten (10) business days from the date of the RAI notice. Medicaid will provide the agency with a follow-up reminder of the due date and documents needed five (5) business days from the date of the RAI notice. 

Effective March 1, 2020, Medicaid will begin issuing letters to PDN agencies addressing non-compliance with the timely submission of required documentation as indicated in the RAI notice. 

• PDN services will only be authorized for the beneficiary for thirty (30) calendar days from the date of the letter to allow the agency a final opportunity to correct this deficiency. 
• If the information is not received within the 30-day authorized period, Medicaid will be unable to continue to authorize the requested PDN services. A copy of this letter will also be sent to the beneficiary/responsible party.