5101:3-12-02.3 Private duty nursing: procedures for service authorization.

(A) As a prerequisite to receiving private duty nursing (PDN) services,

(1) A child must meet the requirements of rule 5101:3-12-02 of the Administrative Code, including paragraph (F)(4)(a) or (F)(4)(b), as applicable, which require the child receive PDN authorization from ODJFS or its designee; or

(2) An adult must meet the requirements of rule 5101:3-12-02 of the Administrative Code, including paragraph (G)(5)(a) or (G)(5)(b), as applicable, which require the adult receive PDN authorization from ODJFS or its designee.

(B) The procedures set forth in this paragraph must be followed when securing a PDN authorization for children and adults who are not enrolled on a home and community-based services (HCBS) waiver. ODJFS shall specify the amount, scope and duration of PDN services to be authorized. The period for which PDN authorization applies shall not exceed one hundred eighty days.

(1) The PDN provider shall submit a referral for PDN authorization to ODJFS on the JFS 02374, "Private Duty Nursing (PDN) Services Request" (9/06), and shall submit any additional supporting documentation requested by ODJFS.

(2) ODJFS shall conduct a face-to-face assessment and/or perform a desk review to determine if, in accordance with rule 5101:3-12-02 of the Administrative Code, the consumer has a medical condition that meets the criteria for an institutional level of care, and the services are medically necessary as set forth in rule 5101:3-1-01 of the Administrative Code.

(a) If ODJFS determines the consumer has a medical condition that meets the criteria for an institutional level of care, and PDN services are medically necessary as set forth in rule 5101:3-1-01 of the Administrative Code, ODJFS shall:

(i) Notify the PDN provider in writing of the authorized amount, scope and duration of PDN services and the PDN authorization number after conducting the face-to-face assessment and/or performing the desk review. The PDN provider shall begin furnishing PDN services to the consumer upon receipt of written PDN authorization and in accordance with all other requirements set forth in rule 5101:3-12-02 of the Administrative Code.

(ii) Inform the consumer and/or authorized representative of PDN authorization after conducting the face-to-face assessment and/or performing the desk review, and provide a written notice to the consumer and/or authorized representative specifying the authorized amount, scope and duration of PDN services.

(b) If the consumer and/or authorized representative disagrees with the authorized amount, scope and/or duration of PDN services, the consumer and/or authorized representative may request a hearing in accordance with division 5101:6 of the Administrative Code. PDN services shall be delivered according to the amount, scope and duration authorized pending the outcome of the hearing.

(c) If ODJFS determines the consumer does not have a medical condition that meets the criteria for an institutional level of care, and/or the services are not medically necessary as set forth in rule 5101:3-1-01 of the Administrative Code, ODJFS:

(i) Shall deny the PDN authorization request, and issue a denial notice and hearing rights to the consumer in accordance with division 5101:6 of the Administrative Code.

(ii) May conduct a review of the PDN authorization request that has been proposed for denial.

(iii) Shall notify the PDN provider in writing of the denial of the PDN authorization request.

(3) The provider shall notify ODJFS in writing on the JFS 02374, "Private Duty Nursing (PDN) Services Request," when there is any change in the consumer's condition that warrants a change in the amount, scope or duration of PDN services.

(C) The procedures set forth in this paragraph must be followed when securing a PDN authorization for children and adults enrolled on an HCBS waiver administered by the Ohio department of mental retardation and developmental disabilities (ODMR/DD) or the Ohio department of aging (ODA). ODJFS shall specify the amount, scope and duration of PDN services to be authorized. The period for which PDN authorization applies shall not exceed three hundred sixty-five days.

(1) The consumer and/or authorized representative, or PDN provider shall request that the ODMR/DD or ODA case manager submit a referral for PDN authorization to ODJFS on the JFS 02374, "Private Duty Nursing (PDN) Services Request," and shall submit any additional supporting documentation requested by ODJFS. The case manager shall assist the consumer and/or authorized representative in securing a potential PDN service provider.

(2) ODJFS shall conduct a face-to-face assessment and/or perform a desk review to confirm if, in accordance with rule 5101:3-12-02 of the Administrative Code, the consumer is enrolled in an ODMR/DD- or ODA-administered waiver, and has a medical condition that requires PDN services that are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code.

(a) If ODJFS confirms, in accordance with rule 5101:3-12-02 of the Administrative Code, the consumer is enrolled in an ODMR/DD- or ODA-administered waiver, and has a medical condition that requires PDN services that are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, ODJFS shall:

(i) Notify the ODMR/DD or ODA case manager, as applicable, in writing of the authorized amount, scope and duration of PDN services and the PDN authorization number after conducting the face-to-face assessment and/or performing the desk review. The ODMR/DD or ODA case manager shall notify the PDN provider of the authorized amount, scope and duration of PDN services and the PDN authorization number, and the PDN provider shall begin furnishing PDN services to the consumer upon receipt of written PDN authorization and in accordance with all other requirements set forth in rule 5101:3-12-02 of the Administrative Code.

(ii) Inform the consumer and/or authorized representative of PDN authorization after conducting the face-to-face assessment and/or performing the desk review, and provide a written notice to the consumer and/or authorized representative specifying the authorized amount, scope and duration of PDN services.

(b) If the consumer and/or authorized representative disagrees with the authorized amount, scope and/or duration of PDN services, the consumer and/or authorized representative may request a hearing in accordance with division 5101:6 of the Administrative Code. PDN services shall be delivered according to the amount, scope and duration authorized pending the outcome of the hearing.

(c) If ODJFS cannot confirm, in accordance with rule 5101:3-12-02 of the Administrative Code, the consumer is enrolled in an ODMR/DD- or ODA-administered waiver, and/or cannot confirm that the consumer has a medical condition that requires PDN services that are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, ODJFS shall:

(i) Deny the PDN authorization request and issue a denial notice and hearing rights to the consumer and/or authorized representative in accordance with division 5101:6 of the Administrative Code.

(ii) Notify the ODMR/DD or ODA case manager in writing of the denial of the PDN authorization request. The ODMR/DD or ODA case manager shall notify the PDN provider in writing of the denial.

(3) The provider shall notify ODJFS and the ODMR/DD or ODA case manager in writing on the JFS 02374, "Private Duty Nursing (PDN) Services Request," when there is any change in the consumer's condition that warrants a change in the amount, scope or duration of PDN services.

(4) The ODMR/DD or ODA case manager shall notify ODJFS in writing on the JFS 02374, "Private Duty Nursing (PDN) Services Request," when there is a change in the consumer's level of care.

(D) PDN services shall be approved for ODJFS-administered waiver consumers as a result of the face-to-face assessment or reassessment conducted by ODJFS or its designated case management agency (CMA) in accordance with rule 5101:3-46-02 of the Administrative Code, or the reassessment conducted in accordance with rule 5101:3-47-02 or 5101:3-50-02 of the Administrative Code, as appropriate. As set forth in rule 5101:3-12-02 of the Administrative Code, PDN services must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code.

(1) The case manager shall assist the consumer and/or authorized representative in securing a PDN service provider.

(2) If PDN services are approved, ODJFS or its designated CMA shall:

(a) Record the amount, scope and duration of approved PDN services on the all services plan.

(b) Notify the provider, in writing, of the amount, scope and duration of approved PDN services.

(c) Inform the consumer and/or authorized representative of PDN service approval after conducting the assessment or reassessment, and provide a written notice to the consumer and/or authorized representative specifying the approved amount, scope and duration of PDN services.

(3) If the consumer and/or authorized representative disagrees with the authorized amount, scope and/or duration of PDN services, the consumer and/or authorized representative may request a hearing in accordance with division 5101:6 of the Administrative Code. PDN services shall be delivered according to the approved amount, scope and duration pending the outcome of the hearing.

(4) If PDN services are denied, ODJFS or its designated CMA shall issue a denial notice and hearing rights to the consumer and/or authorized representative in accordance with division 5101:6 of the Administrative Code.

(5) Requests for a change in the amount, scope and/or duration of authorized PDN services shall be submitted to ODJFS or its designated CMA. ODJFS or its designated CMA shall conduct a face-to-face reassessment and/or perform a desk review to evaluate the request.

(E) PDN services may be provided to a consumer in an emergency when the provider has an existing PDN authorization to provide PDN services to that consumer. For the purposes of this rule, emergency services are provided outside of normal state of Ohio office hours when prior authorization cannot be obtained.

(1) PDN services may be delivered in an emergency and a new PDN authorization obtained after the delivery of services. The PDN services must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, and the services must be necessary to protect the health and welfare of the consumer.

(2) The provider shall notify ODJFS, or the ODMR/DD or ODA case manager, as applicable, in writing on the JFS 02374, "Private Duty Nursing (PDN) Services Request," when emergency PDN services are furnished. Notification shall be immediate, or no later than the first business day following the emergency provision of PDN services.

(F) ODJFS may authorize the provision of PDN services by one or more provider(s) in visits of four hours or less during the authorized PDN service period in order to assure the health and welfare of the consumer. "PDN service period" means the length of time during which PDN services, which are more than four hours in length, are delivered without a two-hour lapse between visits.

(G) Utilization of authorized PDN services is subject to monitoring by ODJFS.

(H) ODJFS shall maintain all written records related to review of PDN service authorization for a period of six years following receipt of the request or until an initiated audit is resolved, whichever is longer.

Replaces: 5101:3-12- 02.3

Effective: 12/07/2006
R.C. 119.032 review dates: 12/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , 5111.85
Prior Effective Dates: 9/1/06 (Emer)