R414-40-3. Program Access Requirements

(1) Only a licensed home health agency enrolled as a Medicaid provider may be reimbursed for private duty nursing service.

(2) A recipient must have a written physician order establishing the need for private duty nursing service. The private duty nursing provider must develop a plan of care consistent with the recipient diagnosis, severity of illness, and intensity of service. The patient must require more than four hours of skilled nursing service. If medically necessary nursing service requires four hours or less of skilled nursing, the service is covered under the home health program.

(3) Medicaid providers shall submit an initial prior authorization request with medical documentation that demonstrates the need for nursing service. The home health agency shall submit an initial certification and a recertification at least every 60 days as required by 42 CFR 440.70.

(4) Private duty nursing is only available if a parent, guardian, or primary caregiver is committed to and capable of performing the medical skills necessary to ensure quality care.

(5) The home health agency shall verify that the hospital has provided specialized training for the caregiver before patient discharge to enable the caregiver to provide hands-on care in the home. The private duty nurse initially supervises the caregiver who provides this care to ensure that training has been assimilated to ensure safe, quality patient care.