Section IIPrivate Duty Nursing Services201.100Private Duty Nursing Services Providers Providers of Private Duty Nursing Services (PDN) must meet the following criteria in order to be eligible for participation in the Arkansas Medicaid Program:
A. The PDN provider must have either a Class A or Class B license issued by the Arkansas Division of Health. It must be designated on the license that the PDN agency is a provider of extended care services.1. A copy of the license must accompany the provider application and Medicaid contract.2. Subsequent licensure must be provided when issued by the Arkansas Division of Health. a. Subsequent license renewal must be forwarded to Provider Enrollment within 30 days of issue. If the renewal documents have not been received within the 30-day deadline, the provider will have an additional and final 30 days to comply.b. Failure to ensure that current licensure is on file with Provider Enrollment will result in termination from the Arkansas Medicaid Program.3. For purposes of review under the Arkansas Medicaid Program, agencies enrolled as Class B operators providing private duty nursing services must adhere to those standards governing quality of care, skill and expertise applicable to Class A operators.B. The PDN provider must complete a provider application (form DMS-652), Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). View or print a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9).C. Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid provider contract. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule, are not eligible to enroll, or to remain enrolled as Medicaid providers.D. The Private Duty Nursing provider must adhere to all applicable professional standards of care and conduct. Providers who have agreements with Medicaid to provide other services to Medicaid beneficiaries must have a separate provider application and Medicaid contract to provide private duty nursing services. A separate provider number is assigned.
201.200School District or Education Service Cooperative Private Duty Nursing Services ProvidersArkansas Medicaid will enroll Arkansas school districts and Education Service Cooperatives (ESC) as Private Duty Nursing Services (PDN) providers when the following criteria are met:
A. The school district or Education Service Cooperative must complete a provider application (form DMS-652), Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). View or print a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9).B. The school district or ESC must be certified by the Arkansas Department of Education (ADE) as a Local Educational Agency (LEA). The ADE will provide verification of LEA certification to the Provider Enrollment Unit of the Arkansas Division of Medical Services. Subsequent certifications must be provided when issued. 1. Subsequent certifications must be forwarded to Provider Enrollment within 30 days of issue. If the certification has not been received within the 30-day deadline, the provider will have an additional and final 30 days to comply.2. Failure to ensure that current certification is on file with Provider Enrollment will result in termination from the Arkansas Medicaid Program.C. Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid provider contract. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule, are not eligible to enroll, or to remain enrolled as Medicaid providers.D. The Private Duty Nursing provider must adhere to all applicable professional standards of care and conduct.203.000Private Duty Nursing Service Providers in States Not Bordering ArkansasA. Providers in states not bordering Arkansas are called limited services providers because they may enroll in Arkansas Medicaid only after they have provided care to an Arkansas Medicaid beneficiary and have a claim to file, and because their enrollment automatically expires. 1. A non-bordering state provider may send a claim to Medicaid Provider Enrollment and Medicaid Provider Enrollment will forward by return mail a provider manual and a provider application and contract. View or print Medicaid Provider Enrollment Unit contact information.2. Alternatively, a non-bordering state provider may download the provider manual and provider application materials from the Arkansas Medicaid website, www.medicaid.state.ar.us, and then submit the application and claim to the Medicaid Provider Enrollment Unit.B. Limited services providers remain enrolled for one year. 1. If a limited services provider treats another Arkansas Medicaid beneficiary during the year of enrollment and bills Medicaid, the enrollment may continue for one year past the newer claim's last date of service, if the provider keeps the enrollment file current.2. During the enrollment period the provider may file any subsequent claims directly to EDS.3. Limited services providers are strongly encouraged to submit claims through the Arkansas Medicaid website because the front-end processing of web-based claims ensures prompt adjudication and facilitates reimbursement.204.000Records Requirements DHHS requires retention of all records for five (5) years. Providers of Private Duty Nursing Services (PDN) must keep and make available to authorized representatives of the Arkansas Division of Medical Services, the State Medicaid Fraud Control Unit, representatives of the Department of Health and Human Services and its authorized agents or officials, records which include:
A. Medicaid contract (form DMS-653) to participate in the Arkansas Medicaid Program.B. Copy of the license of the registered nurse (RN) and/or licensed practical nurse (LPN) providing private duty nursing services.C. Documentation verifying that RNs or LPNs are CPR certified.D. Documentation that the RN or LPN has received in-service training on the particular patient's equipment and care needs.E. Written contracts between contract personnel and the agency.F. Statistical, fiscal and other records necessary for reporting and accountability.G. Copies of the approved Request for Private Duty Nursing Services Prior Authorization and Prescription Initial Request or Recertification (Form DMS-2692). View or print form DMS-2692 and instructions for completion.H. Signed and dated notes on the condition and progress of each patient.I. The patient's PDN care plan (Home Health Certification and Plan of Care (form CMS-485), including written justifications of any modification in the PDN care plan or prescription of service by the physician. View or print form CMS-485.J. Any additional or special documentation deemed necessary by the provider or required by DMS.K. Documentation of PDN services provided to each eligible beneficiary, including the date, the actual time of day each service was delivered and the signature of the person who actually provided the service.205.000 Retention of Records A. Private Duty Nursing Services providers must maintain all records for a period of five (5) years from the date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer.B. Private Duty Nursing Services providers must contemporaneously create and maintain records that completely and accurately explain all evaluations, care, diagnoses and any other activities in connection with any Medicaid beneficiary.C. Private Duty Nursing providers furnishing any Medicaid-covered good or service for which a prescription is required by law, by Medicaid rule, or both, must have a copy of the prescription for such good or service. The provider must obtain a copy of the prescription within five (5) business days of the date the prescription is written.D. Private Duty Nursing providers must maintain a copy of each relevant prescription in the Medicaid beneficiary's records and follow all prescriptions and care plans.E. The Private Duty Nursing provider must immediately make available to the Division of Medical Services, its contractors and designees and the Medicaid Fraud Control Unit all records related to any Medicaid beneficiary.F. At the time of an audit by the Division of Medical Services, Medicaid Field Audit Unit, all documentation must be immediately made available at the provider's place of business during normal business hours. In the case of recoupment, there will be no more than thirty days allowed after the date of the recoupment notice in which additional documentation will be accepted. Additional documentation will not be accepted after the thirty-day period.Failure to furnish records upon request may result in sanctions.
211.000IntroductionThe Arkansas Medicaid Program is designed to assist eligible Medicaid beneficiaries in obtaining medical care within the guidelines specified in this manual.
212.000ScopePrivate duty nursing services are those medically necessary services that are provided by a registered nurse or licensed practical nurse under the direction of the beneficiary's physician, to a beneficiary in his or her place of residence, a Division of Developmental Disabilities Services (DDS) community provider facility or a public school. For purposes of the Medicaid program, private duty nursing services are those medically necessary services related to the coverage described in Section 213.000 and delivered by a registered nurse or licensed practical nurse, as required by the State Nurse Practice Act. The registered nurse or licensed practical nurse providing services may not be a family member or taking on the role of a family member of the Medicaid beneficiary as described in Section 212.100.
212.200Private Duty Nursing Service LocationsA. Medicaid-eligible, ventilator-dependent beneficiaries age 21 and older may receive Private Duty Nursing Services (PDN). PDN services may be provided only in the beneficiary's own home and as necessary when the Medicaid beneficiary's normal life activities temporarily take the beneficiary away from the home. For purposes of this rule, normal life activity means routine work, school, church, office or clinic visits, shopping and social interactions with friends and family. The private duty nurse may accompany the beneficiary but may not drive. Normal life activities do not include non-routine or extended home absences.B. For Medicaid-eligible beneficiaries under the age of 21, PDN services are covered in the following locations: 1. The beneficiary's home. PDN services may be provided only in the beneficiary's own home and as necessary when the Medicaid beneficiary's normal life activities temporarily take the beneficiary away from the home. For purposes of this rule, normal life activity means routine work, school, church, office or clinic visits, shopping and social interactions with friends and family. The nurse may accompany the beneficiary but may not drive. Normal life activities do not include non-routine or extended home absences.2. A public school. A school's location may be an area on or off-site based on accessibility for the student. When a student's education is the responsibility of the school district in which that student resides, "school" as a place of service for Medicaid-covered services is any location, on-site or away from the site of an actual school building or campus, at which the school district is discharging that responsibility.a. When a child is attending school at a DDS community provider facility because the school district has contracted with the facility to provide educational services, the place of service is "school".b. When the home is the educational setting for a child who is enrolled in the public school system, "school" is considered the place of service.c. The student's home is not considered a "school" place of service when a parent elects to home school a child.3. A DDS community provider facility.C. PDN services are not covered at/or in a hospital, boarding home, nursing facility, residential care facility, or an assisted living facility.213.000Coverage of Private Duty Nursing ServicesPrivate Duty Nursing Services (PDN) may be covered for individuals who meet the following requirements:
A. Medicaid-eligible ventilator-dependent beneficiaries when determined medically necessary and prescribed by a physician.B. Medicaid-eligible beneficiaries under age 21 who are:1. In the Child Health Services (EPSDT) Program, and2. High technology non-ventilator dependent beneficiary requiring at least two (2) of the following services, unless the beneficiary requires an extremely high level of one (1) service making a home care plan impossible without private duty nursing services: a. Intravenous Drugs (e.g. chemotherapy, pain relief, or prolonged IV antibiotics)b. Respiratory - Tracheostomy or Oxygen Supplementation c. Total Care Support for ADLs and close patient monitoringd. Hyperalimentation - parenteral or enteral PDN services may be provided by a registered nurse and/or licensed practical nurse as directed by the beneficiary's physician.
All PDN services require prior authorization by the Medicaid Program. Refer to Section 220.000 of this manual for information on the prior authorization process.
213.200Coverage of Private Duty Nursing Medical SuppliesThe Arkansas Medicaid Program covers Private Duty Nursing Services (PDN) medical supplies. Supplies are limited to $80.00 per month, per beneficiary.
Refer to Section 242.130 of this manual for PDN nursing supplies.
214.000Medical Criteria and Guidelines for Coverage of Private Duty Nursing Services for Ventilator-Dependent BeneficiariesThe following medical criteria and guidelines are utilized in evaluating coverage of private duty nursing services for a ventilator-dependent beneficiary:
A. Selection of Patient 1. Medical: The patient must have a related diagnosis requiring ventilator support. These diagnoses are: a. Neuromuscular disease involving the respiratory musclesb. Brainstem respiratory center dysfunctionc. Severe thoracic cage abnormalitiesd. Intrinsic lung diseasee. Lung disease associated with cardiovascular disorders Each patient must have cardiovascular stability.2. Social: The patient must depend upon family members to provide support at home for medical and non-medical care on an ongoing basis.3. Cost Effectiveness: The cost of private duty nursing care should not exceed the cost for acute inpatient hospital care.B. Specific factors to be assessed1. Medical a. Mechanical ventilator support is necessary for at least six (6) hours per day and weaning has been tried but was unsuccessful. b. Frequent ventilator adjustments are unnecessary.c. Oxygen supplementation at or below an inspired fraction of 40% (F1O2@0.40).d. There are no anticipated needs for frequent re-hospitalizations.e. There is a record of reasonable expectation of normal or near-normal growth while receiving ventilator support. (This criterion applies to children only.)2. Social/Emotional/Environmental: Major commitments on the part of family and community are mandatory to meet the beneficiary's extraordinary needs. Specific components include: a. Stable parent or parent figures.b. Caregivers understanding of beneficiary's condition.c. Primary care physician.d. Family must ID at least one (1) additional family member and/or community person beyond the immediate family.e. Demonstrated interest and ability in the care of the patient related to trach care, ventilator management, drug administration, feeding needs and developmental stimulation.f. An adequate physical environment within the home.i. Sufficient resources within the community including emergency medical services, educational and vocational programs and other support programs.l. Transportation requirements.215.000Criteria For Coverage of High Technology, Non-Ventilator Dependent Beneficiaries In the Child Health Services (EPSDT) ProgramSpecific factors to be assessed:
A. Medical 1. Technology dependent children consist of those with medical technology including but not limited to the following. Each category requires a variety of services. The technology dependence is life threatening and requires attention around the clock with 2 or more of the below categories being present. The constancy of care exceeds the family's ability to care for the patient at home on a long-term basis without the assistance of home nursing care. a. Intravenous Drugs (e.g., chemotherapy, pain relief or prolonged IV antibiotics)b. Respiratory -- Tracheostomy or Oxygen Supplementationc. Total Care Support for ADLs and close patient monitoringd. Hyperalimentation - parenteral or enteral2. The technology dependence may be related to any of the following diagnoses. a. Severe neuromuscular, respiratory or cardiovascular disease not requiring mechanical ventilatory support.b. Chronic liver or gastrointestinal disorders with associated nutritional compromise.c. Multiple congenital anomalies or malignancies with severe involvement of vital body functions. d. Serious infections that require prolonged treatment.B. Social/Emotional/Environmental Major commitments on the part of the child's family and community are mandatory to meet the child's extraordinary needs. Specific components include:
1. Stable parent or parent figures.2. Caregivers understanding of beneficiary's condition.3. Primary care physician.4. Family must ID at least one (1) additional family member and/or community person beyond the immediate family.5. Demonstrated interest and ability in the care of the patient related to trach care, drug administration, feeding needs and developmental stimulation.6. An adequate physical environment within the home.9. Sufficient resources within the community including emergency medical services, educational and vocational programs and other support programs.10. Identified stressors.12. Transportation requirements.216.000Exclusions Private duty nursing services will not be authorized for a beneficiary in a boarding home, hospital, nursing facility, residential care facility or any other institutional setting or health care facility.
222.000Request for Prior Authorization A request for prior authorization for private duty nursing services must originate with the provider. The provider is responsible for completion of the Request for Private Duty Nursing Services Prior Authorization and Prescription Initial Request or Recertification (form DMS-2692) and obtaining the required medical information. Form DMS-2692 must be signed by the beneficiary's physician with documentation that a physical examination was performed within 12 months of the beginning of the initial request or the recertification. View or print form DMS-2692 and instructions for completion.
For PDN services in the beneficiary's home a social/environmental evaluation indicating a commitment on the part of the beneficiary's family to provide a stable and supportive home environment must accompany the request for prior authorization. Refer to Section 224.000 of this manual for additional information required for the initial request.
All PA requests for Medicaid-eligible beneficiaries will be evaluated by the Division of Medical Services, Utilization Review (UR) Section, to determine the level of care and amount of nursing services to be authorized. View or print Utilization Review Section contact information.
The UR Section will notify the provider of the approval or denial of the PDN services PA request within 15 working days following the receipt of the PA request. If the PA request for PDN services is approved, page 5 of form DMS-2692 will be returned to the provider with the number of hours approved indicated on the form. The PA number will be assigned after the provider sends in documentation of the actual hours worked.
NOTE: The prior authorization number MUST be entered on the claim form filed for payment of these services. The initial PA approval will only be authorized for a maximum of 90 days. A new request must be made for services needed for a longer period of time. Recertification may be authorized for a maximum of six (6) months. Refer to Section 224.000 of this manual for information regarding recertification of PDN services. The effective date of the PA will be the date the patient begins receiving PDN services or the day following the last day of the previous PA approval.
Providers are cautioned that a prior authorization approval does not guarantee payment. Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time service is provided and upon completeness and timeliness of the claim filed for the service. The provider is responsible for verifying the beneficiary's eligibility.
225.000Filing for Prior Authorization To request prior authorization, the Private Duty Nursing Services (PDN) provider must complete and forward the original and one copy of Form DMS-2692 to the Division of Medical Services Utilization Review Section. View or print the DMS Utilization Review Section contact information.
A copy of the form should be retained in the provider's records.
Additional documentation is required for PDN services for eligible Medicaid beneficiaries under age 21. The following documentation must be provided:
A. Current medical and surgical historyB. Current psychosocial assessmentC. Current PDN care plan (Home Health Certification and Plan of Care - form CMS-485) View or print form CMS-485.
New requests for PDN services should be sent to the Division of Medical Services, Utilization Review Section (UR) as early as possible after the medical need for private duty nursing is identified.
Providers must submit requests for prior authorization of PDN services within 30 days of the beginning date of service. Providers assume the risk of services ultimately being found not medically necessary. When PDN services are approved by UR at the level requested, the effective date of the prior authorization will be retroactive to the beginning date of service.
226.000Appealing An Adverse Action Please see section 190.000 et al for information regarding administrative appeals.
232.000Rate Appeal Process A provider may request reconsideration of a Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Health and Human Services (DHHS) Management Staff, who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
240.000BILLING PROCEDURES241.000 Introduction to Billing Private Duty Nursing providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.
Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission. 242.130 Medical Supplies Procedure Codes The following HCPCS procedure codes must be used when billing the Arkansas Medicaid Program for medical supplies.
A4206 | A4216 | A4217 | A4221 | A4222 | A4253 |
A4256 | A4259 | A4265 | A4310 | A4311 | A4312 |
A4313 | A4314 | A4315 | A4316 | A4320 | A4322 |
A4326 | A4327 | A4328 | A4330 | A4338 | A4340 |
A4344 | A4346 | A4347 | A4348 | A4351 | A4352 |
A4354 | A4355 | A4356 | A4357 | A4358 | A4359 |
A4361 | A4362 | A4364 | A4367 | A4369 | A4371 |
A4397 | A4398 | A4399 | A4400 | A4402 | A4404 |
A4405 | A4406 | A4414 | A4452 | A4454 | A4455 |
A4558 | A4560 | A4561 | A4562 | A4623 | A4624 |
A4625 | A4626 | A4628 | A4629 | A4772 | A4927 |
A5051 | A5052 | A5053 | A5054 | A5055 | A5061 |
A5062 | A5063 | A5071 | A5072 | A5073 | A5081 |
A5082 | A5093 | A5102 | A5105 | A5112 | A5113 |
A5114 | A5119 | A5121 | A5122 | A5126 | A5131 |
A6154 | A6234 | A6241 | A6242 | A6248 | A6441 |
A6442 | A6443 | A6444 | A6445 | A6446 | A6447 |
A6448 | A6449 | A6450 | A6451 | A6452 | A6453 |
A6454 | A6455 | A7520 | A7521 | A7522 | A7524 |
National HCPCS Codes
Procedure Code | Required Modifier | Description |
A6257 | | Transparent Film, each (16 square inches or less) |
A6258 | | Transparent Film, each (more than 16, but less than 48 square inches) |
A6259 | | Transparent Film, each (more than 48 square inches) |
A6216 A6219 A6228 | | Gauze Pad, Medicated or Non-Medicated, each (16 square inches or less) |
A6220 A6229 A6217 | | Gauze Pads, Medicated or Non-Medicated, each (more than 16, but less than 48 square inches) |
A6221 A6230 A6218 | | Gauze Pads, Medicated or Non-Medicated, each (more than 48 square inches) |
A4450 | | Gauze, Non-Elastic, Per Roll (1 linear yard) |
A6245 A6242 | | Hydro gel Dressing, each (16 square inches or less) |
A6246 | | Hydro gel Dressing, each (more than 16, but less than 48 square inches) |
A6247 A6244 | | Hydro gel Dressing, each (more than 48 square inches) |
A6248 | | Hydro gel Dressing, each (1 ounce) |
A6237 A6234 | | Hydrocolloid Dressing, each (16 square inches or less) |
A6238 A6235 | | Hydrocolloid Dressing, each (more than 16, but less than 48 square inches) |
A6236 A6239 | | Hydrocolloid Dressing, each (more than 48 square inches) |
A6196 | | Alginate Dressing, each (16 square inches or less) |
A6197 | | Alginate Dressing, each (more than 16, but less than 48 square inches) |
A6198 | | Alginate Dressing, each (more than 48 square inches) |
A6197 | UB | Alginate Dressing, each (1 linear yard) |
A6209 | | Foam Dressing, each (16 square inches or less) |
A6210 | | Foam Dressing, each (more than 16, but less than 48 square inches) |
A6211 | | Foam Dressing, each (more than 48 square inches) |
A6200 | | Composite Dressing, each (16 square inches or less) |
National HCPCS Codes
Procedure Code | Required Modifier | Description |
A6201 | | Composite Dressing, each (more than 16, but less than 48 square inches) |
A6202 | | Composite Dressing, each (more than 48 square inches) |
A4253 | UB | Blood Glucose test or reagent strip for home blood glucose monitor, per 25 strips |
A4353 | | Urinary intermittent catheter with insertion tray |
A4394 | | Ostomy deodorant, all types, per ounce |
A4365 | | Adhesive remover wipes, 50 per box |
A4368 | | Ostomy filters, any type, each |
A4483 | | Tracheostomy vent-heat moisture device |
L8239* | | Stocking (Jobst) |
A6549* | | Gradient compression stocking, not otherwise specified |
* Refer to section 242.430.
242.200Place of Service and Type of Service CodesPlace of Service | Paper Claims | Electronic Claims |
Patient's home | 4 | 12 |
DDS Facility (for beneficiaries under age 21, not school age) | 5 | 52 |
Public School (for beneficiaries under age 21) | S | 03 |
Type of Service (paper only)
1-Private Duty Nursing Services
S-Public School (for beneficiaries under age 21) NOTE: Type of service code "S" requires the LEA number of the school district in Field 19 of the CMS-1500.
242.410Private Duty Nursing Billing Procedures Private duty nursing services (PDN) are billed on a per unit basis. One unit equals one hour. Arkansas Medicaid will reimburse for the actual amount of cumulative PDN time on a monthly basis. Service time of less than one hour may not be rounded up to a full hour.
Type of service code "1" must be used when filing paper claims. Public schools must use type of service code "S" when filing paper claims for beneficiaries under age 21.
Refer to Sections 242.110 and 242.120 for PDN procedure codes for single patient care and multiple patient care.
242.430Private Duty Nursing Medical Supplies Procedure code L8239 must be prior authorized. Form DMS-679 may be used to request prior authorization. View or print form DMS 679.
Procedure code A6549, with types of service "S" and "1", must be manually priced. Procedure code A6549 with a type of service of "1" requires a prior authorization (PA).
Refer to Section 242.130 for procedure codes of covered medical supplies.