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Cook Children's Health Plan

Private Duty Nursing

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:

  • Children’s Services Comprehensive Care Program (CCP) prior authorization request form
  • Home health Plan of Care (POC) form
    • An alternative, more inclusive POC, appropriate signed by the order provider and PDN agency nurse (RN) may replace this requirement.
  • Six month CCP prior authorization PDN (when asking for more than three months)
  • Nursing addendum to POC, including, including 24-hour flowsheet

Routine authorization requests will be processed within three business days from Cook Children’s Health Plan receiving 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.

  • Urgent requests need to be submitted with all documentation signed
  • Urgent requests will be processed within 24 hours

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 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:

  • A completed CCP Prior Authorization Request Form
  • Reason for revision
  • Dates of service for new hours
  • Provider signature

To request a provider change when the Member has active authorization, submit the following:

  • Private duty nursing authorization request packet
    • Four forms as listed above
    • Initial authorization requests can only be approved for a maximum of 90 days, or the remainder of current authorization period.
  • Change of Provider form
    • Date of last service with old agency
    • Date of service to start with new agency
    • Primary caregiver with signature and date

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.”