Author: GDIT, (800) 688-6696
Private Duty Nursing (PDN) – Beneficiaries Under 21 Years of Age
Clinical Coverage Policy 3G-2, Private Duty Nursing for Beneficiaries Under 21 Years of Age, allows for State Plan PDN services to be authorized whenever a beneficiary receiving nursing services through Local Education Agencies (LEAs) has an unscheduled school absence.
- A parent or caregiver signed notification explaining any unscheduled school absences is required for PDN agency reimbursement of hours worked in the home.
- Once required documentation has been received by NC Medicaid, the Prior Authorization (PA) for the affected time frame is adjusted to document the hours provided at the primary private residence.
With the direction of Governor Cooper to close school systems state-wide due to COVID-19, NC Medicaid is temporarily lifting the requirement for PA to be obtained when additional PDN hours are needed to cover unscheduled school closures for beneficiaries that have a current PDN PA certification. Claims submitted may be subject to audit for each program.
Private Duty Nursing (PDN) – All Beneficiaries
Clinical Coverage Policy 3G-1, Private Duty Nursing for Beneficiaries Age 21 and Older, Section 3.4.1 and Clinical Coverage Policy 3G-2, Private Duty Nursing for Beneficiaries Under 21 Years of Age, Section 3.4.3, include coverage for a short- term increase (STI) in PDN services up to four (4) calendar weeks for a significant change in a beneficiary’s condition.
- Refer to the policies addressed above for the qualifying conditions.
- The amount and duration of the short-term increase is based on medical necessity and approved by NC Medicaid’s PDN Nurse Consultant.
To avoid delays in beneficiaries receiving needed PDN STI services, NC Medicaid is temporarily lifting the requirement for PA to be obtained for STI hours for any PDN beneficiary that has a current PDN PA certification.
Home Health – All Beneficiaries
Clinical Coverage Policy 3A, Home Health Services, limits a beneficiary’s annual nursing visits to 75 per year and home health aide visits to 100 annually. To support Home Health beneficiaries remaining in their residence and to lift the administrative burden for the providers during the COVID-19 outbreak, the visit limit is temporarily being lifted.
The Home Health fee schedule is being updated to include coverage of masks when billed with HCPCS code A4928 – surgical mask, in conjunction with Revenue Code 270, during the COVID-19 outbreak.
Community Based Services Clinical Coverage Policies are located here.
Additional information for Medicaid providers is available here.