Lawriter - OAC - 5160-12-02.3 Private duty nursing: procedures for service authorization.

5160-12-02.3 Private duty nursing: procedures for service authorization.

(A) As a prerequisite to receiving private duty nursing (PDN) services, an individual must meet the requirements set forth in rule 5160-12-02 of the Administrative Code, as applicable, which require the individual to receive PDN authorization from the Ohio department of medicaid (ODM) or its designee.

(B) The procedures set forth in this paragraph must be followed when securing a PDN authorization for individuals who are not enrolled on a home and community-based services (HCBS) waiver.

(1) The PDN provider shall submit a referral for PDN authorization to ODM using the ODM 02374, "Private Duty Nursing (PDN) Services Request" (3/2015), along with any additional supporting documentation requested by ODM.

(2) ODM shall conduct an in-person assessment and/or perform a desk review to determine if, in accordance with rule 5160-12-02 of the Administrative Code, the individual has a medical condition that meets the criteria for an comparable institutional level of care, including a nursing facility-based level of care, and the services are medically necessary as set forth in rule 5160-1-01 of the Administrative Code.

(a) If ODM determines the individual has a medical condition that meets the criteria for a nursing facility-based level of care, and PDN services are medically necessary as set forth in rule 5160-1-01 of the Administrative Code, ODM shall:

(i) Notify the PDN provider in writing of the authorized amount, scope and duration of PDN services and the PDN authorization number. The PDN provider shall begin furnishing PDN services to the individual upon receipt of written PDN authorization and in accordance with all other requirements set forth in rule 5160-12-02 of the Administrative Code.

(ii) Inform the individual of the PDN authorization, specifying the authorized amount, scope and duration of PDN services.

(b) If the individual disagrees with the authorized amount, scope and/or duration of PDN services, the individual may request a hearing in accordance with division 5101:6 of the Administrative Code.

(c) If ODM determines the individual does not have a medical condition that meets the criteria for an institutional level of care, including a nursing facility-based level of care, and/or the services are not medically necessary as set forth in rule 5160-1-01 of the Administrative Code, ODM:

(i) May conduct an additional review of the PDN authorization request that has been proposed for denial, and/or

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

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

(3) The provider shall notify ODM in writing using the ODM 02374 when there is any change in the individual's condition that the provider believes may warrant 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 individuals enrolled on an HCBS waiver administered by the Ohio department of aging (ODA) if applicable for an adult. The period for which PDN authorization applies shall not exceed three hundred sixty-five days.

(1) The individual, or PDN provider shall request that the ODA case manager if applicable, submit a referral for PDN authorization to ODM using the ODM 02374 along with any additional supporting documentation requested by ODM. The case manager shall assist the individual in securing a potential PDN service provider.

(2) ODM shall conduct an in-person assessment and/or perform a desk review to determine if, in accordance with rule 5160-12-02 of the Administrative Code, the individual is enrolled on an ODA administered waiver as applicable for an adult, and has a medical condition that requires PDN services that are medically necessary in accordance with rule 5160-1-01 of the Administrative Code.

(a) If ODM determines, in accordance with rule 5160-12-02 of the Administrative Code, the individual is enrolled on an ODA administered waiver, and has a medical condition that requires PDN services that are medically necessary in accordance with rule 5160-1-01 of the Administrative Code, ODM shall:

(i) Notify the ODA case manager, as applicable, in writing of the authorized amount, scope and duration of PDN services and the PDN authorization number. The ODA case manager shall notify the PDN provider of the authorized amount, scope and duration of PDN services and the PDN authorization number. The PDN provider shall begin furnishing PDN services to the individual upon receipt of written PDN authorization and in accordance with all other requirements set forth in rule 5160-12-02 of the Administrative Code.

(ii) Inform the individual of PDN authorization specifying the authorized amount, scope and duration of PDN services.

(b) If the individual disagrees with the authorized amount, scope and/or duration of PDN services, the individual may request a hearing in accordance with division 5101:6 of the Administrative Code.

(c) If ODM cannot confirm, in accordance with rule 5160-12-02 of the Administrative Code, the individual is enrolled on an ODA administered waiver, and/or cannot confirm that the individual has a medical condition that requires PDN services that are medically necessary in accordance with rule 5160-1-01 of the Administrative Code, ODM shall:

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

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

(3) The provider shall notify ODM and the ODA case manager in writing using the ODM 02374 when there is any change in the individual's condition that the provider believes may warrant a change in the amount, scope or duration of PDN services.

(4) The ODA case manager shall notify ODM in writing using the ODM 02374 when there is a change in the individual's level of care.

(D) The procedures set forth in this paragraph must be followed when obtaining PDN approval for an individual enrolled on a HCBS waiver administered by the Ohio department of developmental disabilities (DODD). The period for which PDN approval applies shall not exceed three hundred sixty-five days.

(1) The individual, or PDN provider shall request that the county board services and support administrator (SSA) submit a referral for PDN services to the designee at DODD along with any additional supporting documentation requested by DODD. The county board SSA shall assist the individual in securing a potential PDN service provider.

(2) DODD shall determine if, in accordance with rule 5160-12-02 of the Administrative Code, the individual has a medical condition that requires PDN services which are medically necessary, as set forth in rule 5160-1-01 of the Administrative Code.

(a) If DODD determines the individual has a medical condition that requires PDN services which are medically necessary, DODD shall notify the county board SSA in writing of the authorized amount, scope and duration of PDN services.

(i) County board SSA shall notify the PDN provider of the authorized amount, scope and duration of PDN services. The PDN provider shall begin furnishing PDN services to the individual upon receipt of written PDN approval and in accordance with all other requirements set forth in rule 5160-12-02 of the Administrative Code.

(ii) County board SSA shall inform the individual of PDN authorization specifying the authorized amount, scope and duration of PDN services.

(b) If the individual disagrees with the authorized amount, scope and/or duration of PDN services, the individual may request a hearing in accordance with division 5101:6 of the Administrative Code.

(c) If DODD determines the individual does not have a medical condition that requires PDN services and/or the services are not medically necessary as set forth in rule 5160-1-01 of the Administrative Code, DODD:

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

(ii) Shall notify the county board SSA and the PDN provider of the denial of the PDN authorization request.

(E) PDN services shall be approved for individuals enrolled on an ODM administered HCBS waiver as a result of the in-person assessment or reassessment conducted by ODM or its designee in accordance with rule 5160-46-02 of the Administrative Code, or the reassessment conducted in accordance with rule 5160-50-02 of the Administrative Code. As set forth in rule 5160-12-02 of the Administrative Code, PDN services must be medically necessary in accordance with rule 5160-1-01 of the Administrative Code.

(1) The case manager shall assist the individual in securing a PDN service provider.

(2) If PDN services are approved, ODM or its designee 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 individual of PDN service approval in writing after conducting the assessment or reassessment, and provide a written notice to the individual specifying the approved amount, scope and duration of PDN services.

(3) If the individual disagrees with the authorized amount, scope and/or duration of PDN services, the individual may request a hearing in accordance with division 5101:6 of the Administrative Code.

(4) If PDN services are denied, ODM or its designee shall issue a denial notice and hearing rights to the individual 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 ODM or its designee. ODM or its designee shall conduct an in-person reassessment and/or perform a desk review to evaluate the request.

(F) Additional PDN services beyond what ODM or its designee has authorized may be provided to an individual in an emergency when the provider has an existing PDN authorization to provide PDN services to that individual. 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 5160-1-01 of the Administrative Code, and the services must be necessary to protect the health and welfare of the individual.

(2) The provider shall notify ODM, or the ODA case manager, as applicable, in writing using the ODM 02374, or the county board SSA for individuals enrolled on a DODD administered waiver when emergency PDN services are delivered. Notification shall be immediate, or no later than the first business day following the emergency provision of PDN services.

(G) The provider shall maintain all written records related to the provision of PDN service and its authorization for a period of six years following receipt of the request or until an initiated audit is resolved, whichever is longer.


Effective: 7/1/2017
Five Year Review (FYR) Dates: 07/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70, 5166.02
Prior Effective Dates: 9/1/06 (Emer), 12/07/06, 7/1/15.