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Overview
Private Duty Nursing (PDN) is a benefit for Health First Colorado for members to receive face-to-face skilled nursing that is more individualized and continuous than nursing care that is available under the home health benefit or routinely provided in a hospital or nursing facility. This service is ordered by the attending physician and a plan of care is developed and carried out by the Home Health agency.
FAQ
Q: What is the current status of Private Duty Nursing Prior Authorization Requests (PAR)?
- A: After approving all PDN PARs since October 2022 to address concerns, on May 1, 2023, the normal PDN PAR process fully resumed. Over the last few months, to address stakeholder concerns, the Department of Health Care Policy and Financing (HCPF) has revised the denial notices to include plain language, increased readability and clarity around dates of service, and member-specific reasons for the PAR determination. HCPF has provided additional resources for members for appeals and other services, along with conducting stakeholder engagement.
Extensive training and technical assistance has occurred with all PDN agencies as well as re-reviews of Kepro decisions to ensure alignment with HCPF PDN policy. Starting in April 2023, Kepro returned to reviewing all PDN requests within the contractually required 10 business days.
HCPF’s goal is to ensure Colorado has programs that provide people with access to the services they need, which is especially important for members with complex healthcare needs. We are continuously evaluating how to best balance our responsibility to ensure our members have timely access to care and the federal responsibility to demonstrate all authorized services are medically necessary at the level approved.
Q: What happens to the PDN PAR if I decide to switch to a different Home Health Agency? (Updated 4/17/24)
- A: If a member with an active PDN PAR decides to transfer care to another Home Health Agency, the current PAR must be end dated and a new PAR request must be submitted by the new agency along with the Change of Provider form. This form ends the existing PAR and provides Kepro with a reference to the previous determination.
Q: Why did the RAE reach out to me and what can they help me with?
- A: The Regional Accountable Entities (RAE) reached out to help you find and coordinate other services you may be eligible to receive. Your regional organization, or RAE, manages your physical and behavioral health care. Your regional organization supports a network of providers to make sure you can get care for your body, vision, mental health, and substance use in a coordinated way. Each RAE was provided a list of all members who received a denial so they could conduct that outreach and provide any needed support for coordinating other services.
Q: What is program approval?
- A: Program approval is when HCPF issues a programmatic approval for services even though the services are not determined medically necessary. For some members, the clinical information provided did not demonstrate the medical necessity of the hours requested. Some of the hours that were determined to not meet medical necessity were programmatically approved by HCPF because they had been previously reviewed for medical necessity and approved as part of the utilization management process.
Q: My Home Health Agency mentioned a Step Down Process. Where can I find more information?
- A: The step-down process is used as a gradual reduction in service hours when services are reduced by more than 30%. This gradual reduction facilitates a smoother transition for members to their new level of approved nursing services. It also gives the member and their Regional Accountable Entity (RAE) time to identify and connect with alternative services or other resources in the community. Lastly, it allows caregivers and providers a three-month period of time to make necessary budget adjustments. This is the same step-down process that was used for long-term home health PARs and is applied in the same way to PDN. The process description, including an example, is posted on the PDN website.
Q: Was EPSDT reviewed when the PAR was being reviewed by Kepro?
- A: Yes, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is reviewed for each case, on an individualized basis. However, there are no fixed criteria as that would be contrary to EPSDT requirements. Kepro reviews all information submitted by the home health agency and determines if the requested hours meet the definition of PDN and are medically necessary, including whether the requested services would “correct or ameliorate” the child or youth member’s illnesses or conditions, consistent with Section 1905(a) of the Social Security Act. Due to the individual nature of these reviews, HCPF communicates in each letter that the review took place.
Q: What is intermittent care?
- A: Intermittent care means visits that have a distinct start time and stop time and are task-oriented with the goal of meeting a member’s specific needs for that visit. This is defined in the Colorado Code of Regulations in section 10 CCR 2505-10 8.520.1.M. Intermittent nursing is applied to complete tasks such as an assessment, care planning, implementation of treatment, and evaluation of progress towards goals. These intermittent interventions still require the skills and knowledge of a skilled nurse and cannot be delegated; however, the documentation reflects the intermittent nature of care rather than the continuous and ongoing care under PDN. For example, a nurse comes to the home for a single visit each day to give a member IV medications. The same considerations of the Nurse Practice Act and the Medical Standards of Care are applied to this type of service when reviewed.
Q: Kepro has pended my PAR for additional information. What does that mean?
- A: Requests for Additional Information will be initiated by Kepro if or when there is not enough supporting documentation to complete a review. The submitting provider agency must provide the requested additional information to Kepro within seven (7) business days of the request. The PAR is on hold until supplemental information is received. Supporting documentation may include but is not limited to visit notes, oxygen or seizure logs, physician specialty notes, etc., that detail the level of medical necessity required for PDN.
Q: What other documentation can my Home Health Agency submit for consideration of the PAR?
- A: Further documentation to support the more continuous nature of the request may include but is not limited to, the following:
- Nursing notes or physician specialty or allowed practitioner notes that indicate the nature of services provided and detail the amount, duration, frequency, and goals of skilled nursing services.
- Details of technology dependence and co-morbidities that necessitate the need for skilled nursing.
- Frequency of assessment to include vital signs, interventions to support care and prevent hospitalization, health status assessment indicative of actual needs and stability.
- Respiratory management which can include BiPAP/CPAP management, nebulizer therapy, chest physiotherapy, oxygen management, suctioning, tracheostomy and ventilator management.
- Skilled nursing needs such as blood draws, accessing central or peripheral lines, infusion therapy, IV infusions, non-infusion medications, skin and wound care management, and nutrition management of enteral feeding, with or without complications.
- Seizure control and interventions.
- Activities of daily living (ADL)/therapy support at a skilled nursing level of care.
Q: How long does it take to have my PAR reviewed?
- A: Standard review (most common) occurs for most prior authorization requests (PAR) and will be completed in no more than 10 business days.
- Rapid review (following business day) occurs when a longer turnaround time could delay the Health First Colorado member receiving care or services that would be detrimental to their ongoing, long-term care.
- Expedited review (4 business hours) occurs because a delay could jeopardize the life/health of the member or jeopardize the ability to regain maximum function and/or be subject to severe pain.
- It is helpful to note that incomplete submissions or the need to request additional information can delay this process and extend timelines.
Q: What is a medical necessity review for PDN PARs?
- A: HCPF’s Utilization Review Contractor (URC) conducts a medical necessity review to determine if the services being requested are medically necessary. During the review, the URC reviews the requested nursing services to determine if they are continuously applied throughout the shift; meaning a nurse continually assesses, plans, evaluates, and implements interventions. These continuous assessments and interventions require the skills and knowledge of the skilled nurse and cannot be delegated. The documentation must reflect the continuous nature of the skilled nursing and there must be reasonable evidence that necessary interventions are frequent and current to be considered at the PDN level. This does not include care that is standby in nature or considered protective oversight. Medical necessity reviews always consider the Nurse Practice Act and the Medical Standards of Care.
Q: What are my options if I receive a denial for PDN services?
- A: Members began receiving notices in March 2023, with each member receiving a decision letter (notice) by the end of April 2023. This includes denial notices. If a member receives a denial notice, services continue for 15 calendar days after the denial notice is mailed. If a member decides to appeal the denial, services will remain in place during the course of the appeal.
If Kepro determines all or a portion of the requested hours are not medically necessary, members receive an explanation of the determination in their denial notice as well as their appeal rights. At the same time the member receives the notice, providers will also receive a notification from Kepro about the determination.
Q: I want to file an appeal. How do I do that and what are the timelines?
- A: You have the right to appeal the decision if you disagree with it. Your request for an appeal must be received by the Office of Administrative Courts within 60 calendar days from the date of the notice. Instructions for how to appeal are at the end of your decision letter. You can ask for an appeal hearing by filling out the “Appeal Request Form,” attached to your denial letter, or by writing a letter, or by requesting an appeal online. You can learn more about appeals in the Member Handbook. If you file an appeal, your services will continue during the appeal until the final agency decision.
Q: Do I have to pay back the services that I receive if my appeal is denied?
- A: If your denial is upheld during the appeal process, you do not have to pay back the cost of services you received during that appeal period.
Q: What is happening with the PDN Acuity Tool?
- A: Through the American Rescue Plan Act (ARPA), states received funding to use for enhancing Home and Community Based Services (HCBS) and some state plan services. Through this funding, HCPF has sought a vendor to create a new valid and reliable medical necessity tool for determining PDN needs. This project is in the beginning stages and HCPF anticipates being able to pilot a new PDN acuity tool in mid-2024. For more information about this and other APRA projects, please visit our ARPA website.
Q: Does the current PDN Acuity Tool determine the authorized PDN hours?
- A: The current PDN tool is one component the Utilization Management (UM) vendor utilizes to determine medical necessity. Home health agencies should submit documentation within the plan of care for the services a nurse will perform directly related to the items indicated on the acuity tool.
Q: What regulatory work is being done to help improve this benefit?
- A: As a result of stakeholder engagement, HCPF has committed to reviewing and revising, where needed, the PDN regulations. The revisions aim to provide clarity where needed and update any outdated language or policy. HCPF held the first review meeting on February 23, 2023. The meetings occur every other month to allow HCPF staff time to prepare documents and respond to feedback received. Each meeting focuses on a different section of the regulations so it is easier to focus the conversation and allow in-depth review of each topic. HCPF expects to wrap up the meetings in the Fall of 2023 with a presentation of all changes occurring early in the year 2024.
Q: How can I be involved in this regulatory work?
- A: Your participation in the regulatory work is welcomed! HCPF, in partnership with stakeholders, is revising the regulations pertaining to PDN. Visit our PDN website for all stakeholder engagement meetings, calendar information, meeting materials, etc.
Q: Who can I contact if I have more program or policy questions regarding the PDN benefit?
- A: Email the Home Health Inbox at homehealth@state.co.us for additional support.
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