1. (a) Private duty nursing benefits include the following services.

   1. (1) Direct skilled nursing care and caregiver training and education intended to:

      1. (A) optimize client health status and outcomes; and

      2. (B) promote and support family-centered, community-based care as a component of an array of service options by:

         1. (i) preventing prolonged and/or frequent hospitalizations or institutionalization;
         2. (ii) providing cost-effective, quality care in the most appropriate environment; and
         3. (iii) providing training and education of caregivers.

   2. (2) Amount and duration.

      1. (A) The amount and duration of private duty nursing services requested will be evaluated based upon review of the following documentation:

         1. (i) frequency of skilled nursing interventions;
         2. (ii) complexity and intensity of the client's care;
         3. (iii) stability and predictability of the client's condition; and
         4. (iv) identified problems and goals.

      2. (B) The amount of private duty nursing should be re-evaluated when:

         1. (i) one or more of the client's problems documented in the plan of care are resolved;
         2. (ii) one or more of the goals documented in the plan of care are met;
         3. (iii) there is a change in the frequency of skilled nursing interventions, or the complexity and intensity of the client's care;
         4. (iv) alternate resources for comparable care become available; or
         5. (v) the primary care giver becomes able to meet more of the client's needs.

      3. (C) 24-hour private duty nursing will be authorized only:

         1. (i) for limited periods of time with defined end dates when medically necessary and appropriate based on the needs of the client;
         2. (ii) for limited periods of time with defined end dates related to the medical needs of the primary care giver, only when the alternate care giver is not available; and
         3. (iii) in the absence of both the primary care giver and the alternate caregiver, if another alternate person is designated who can legally make decisions on behalf of the client and who will reside in the client's home during the time 24-hour private duty nursing will be provided.

2. (b) Private duty nursing service limitations include the following:

   1. (1) THSteps-CCP will not reimburse for private duty nursing services used for or intended to provide:

      1. (A) respite care;
      2. (B) child care;
      3. (C) activities of daily living for the client;
      4. (D) housekeeping service; or
      5. (E) individualized, comprehensive case management beyond the service coordination required by the Texas Nursing Practice Act, Texas Occupations Code, §301.001 et seq.
   2. (2) Private duty nursing shall neither replace parents or guardians as the primary care giver nor provide all the care that a client requires to live at home. Primary care givers remain responsible for a portion of a client's daily care, and private duty nursing is intended to support the care of the client living at home.

   3. (3) Authorization of services.

      1. (A) Authorization is required for payment of services.
      2. (B) Only those services that are determined by HHSC or its designee to be medically necessary and appropriate will be reimbursed.
      3. (C) No authorization for payment of private duty nursing services may be issued for a single service period exceeding six months. Specific authorizations may be limited to a time period less than the established maximum based on the stability and predictability of the client.
      4. (D) The family will be notified in writing by HHSC or its designee of the approval, reduction, or denial of requested private duty nursing services.
      5. (E) The provider will be notified in writing by the HHSC or its designee of the approval, reduction, or denial of requested private duty nursing services.

      6. (F) Authorization requests for private duty nursing services must include the following:

         1. (i) current HHSC authorization form, completed by the primary physician and provider;
         2. (ii) plan of care, recommended, signed and dated by the client's primary physician. The primary physician reviews and revises the plan of care with each authorization, or more frequently as the physician deems necessary; and
         3. (iii) current HHSC form, THSteps-CCP Private Duty Nursing Services Addendum to Plan of Care.
      7. (G) If inadequate or incomplete information is provided, the provider will be requested to furnish additional documentation to enable HHSC to make a decision on the request.

      8. (H) For authorization of extensions beyond the initial authorization period or revisions to an existing authorization, the provider must submit requests in writing. Required documentation for extending or revising authorization includes:

         1. (i) current HHSC authorization form;
         2. (ii) plan of care, recommended, signed and dated by the client's primary physician; and
         3. (iii) current HHSC form, THSteps-CCP Private Duty Nursing Services Addendum to Plan of Care, signed and dated by the client's primary physician.
      9. (I) During the authorization process, providers are required to deliver the requested services from the start of care date. Providers are responsible for a safe transition of services when the authorization decision is a denial or reduction in the private duty nursing services being delivered.

Source Note:The provisions of this §363.311 adopted to be effective March 31, 1999, 23 TexReg 13077; transferred effective September 1, 2002, as published in the Texas Register December 6, 2002, 27 TexReg 11527; amended to be effective January 1, 2006, 30 TexReg 8661.