Private Duty Nursing (PDN) providers can find answers to frequently asked questions, information on criteria, policy and procedures, and links to required documentation.
The PDN authorization request packet include the following forms:
Routine authorization requests will be processed within three (3) business days from the date Cook Children’s Health Plan received the request.
An urgent condition means a health condition, including an urgent behavioral health situation, that is not an emergency but is severe or painful enough to cause a prudent layperson, possessing the average knowledge of medicine, to believe that his or her condition requires medical treatment evaluation or treatment within twenty four (24) hours by the Member’s Primary Care Provider or Primary Care Provider designee to prevent serious deterioration of the Member’s condition or health.
Cook Children’s Health Plan does not provide private duty nursing authorization extensions due to inability to obtain required signatures. We will authorize medically necessary PDN retrospectively within thirty (30) days of the start of care date.
For an increase in the units on the prior authorization, when the Member has active authorization, please submit the following:
To request a provider change when the Member has active authorization, submit the following:
Per Texas Medicaid Provider Procedures Manual, Home Health Nursing and PDN Services Handbook:
“The SOC is the date that care is to begin, as agreed on by the family, the client’s physician, and the Provider, and as listed on the POC and the CCP Prior Authorization Request Form. Providers are responsible for determining whether they can accept the client for services.
Once the provider accepts a client for service and accepts responsibility for providing PDN, the provider is required to deliver those services beginning with the SOC date. Providers are responsible for a safe transition of services when the authorization decision is a denial or a reduction of services.
Providers are required to notify the physician and the client’s family on receipt of an authorization, a denial, or a change in PDN. During the prior authorization process for initial and recertification requests, providers are required to deliver the requested services from the SOC date.”