SPECIAL BULLETIN COVID-19 #38; Private Duty Nursing Clinical Policy Modification – Prior Approval Status Due to Refusal of PDN Services

Current Policy: Private Duty Nursing (PDN) Clinical Coverage Policy 3G-1. Private Duty Nursing for Beneficiaries Age 21 and older and Private Duty Nursing (PDN) Clinical Coverage Policy 3G-2 Private Duty Nursing for Beneficiaries Age Under 21 years of age section 5.2.4.1:

(d) If services are terminated as a result of the beneficiary’s loss of Medicaid, or if no PDN services are provided during the 30 consecutive days for any reason such as a hospitalization, then the prior approval process must be initiated once again as outlined in Subsections 5.1 and 5.2. 

However, to support PDN beneficiaries and/or their caregiver’s decision to not receive PDN Nursing services during the COVID-19 pandemic crisis, effective March 10, 2020, NC Medicaid will temporarily leave the affected prior approval (PA) request in pending status to avoid initiating the PA process again on/after 30 consecutive days without PDN services being provided per the following guidelines:

• PDN provider(s) will notify NC Medicaid and the beneficiary’s physician that the beneficiary and/or caregiver has refused PDN nursing services for the duration of the COVID-19 pandemic crisis. This notification is to occur on or before the 10th consecutive day of refusal of PDN nursing services.
• PDN provider(s) will submit an individual coordination statement with the beneficiary’s / caregiver’s decision and physician notification (date and time) to the PA once services are suspended. In addition, the 485 certification dates will be kept current while services are suspended with supplemental documentation of ongoing communication with the beneficiary and/or caregiver. 
• PDN provider(s) will notify NC Medicaid and submit an individual coordination statement to the PA, with the beneficiary’s/caregiver’s decision to resume services and physician notification (date and time).
• These temporary changes will end the earlier of the cancellation of the North Carolina state of emergency declaration or when this policy is rescinded.

Questions regarding the temporary changes in this bulletin may be sent to Medicaid.COVID19@dhhs.nc.gov. 

Author: GDIT, (800) 688-6696