23 Miss. Code. R. 223-5.4 - Prior Authorization and Concurrent Reviews
A.
Private duty nursing (PDN) providers employing Certified Nursing Assistants
(CNAs) must submit a prior authorization request to the Division of Medicaid or
designee at least two (2) weeks prior to the initiation of personal care
services (PCS) that must include, at a minimum, the following:
1. A signed physician or specialist's order
for PCS and a signed initial Plan of Care (POC),
2. Beneficiary diagnosis(es),
3. Skilled teaching/instructions to be
provided to a family member or caregiver(s),
4. Treatment plan/physician orders specifying
each skill to be performed,
5.
Expected duration of service,
6.
Identification of any other home care services, including the hours, days, and
times of these services being provided, including, but limited to:
a) Case management,
b) Physical therapy,
c) Speech therapy,
d) Occupational therapy,
e) Respiratory therapy,
f) Respite,
g) Hospice, and/or
h) Private duty nursing.
7. When PCS medical necessity criteria are no
longer met, a plan:
a) For reducing and
discontinuing PCS hours, and
b) To
transition the beneficiary to the most appropriate setting.
B. A PDN provider
employing a CNA must submit a recertification to the Division of Medicaid or
designee stating the necessity of PCS for each subject beneficiary every six
(6) months indicating the number of hours per day or week and the duration of
the request and include the following:
1. An
updated POC,
2. Progress
notes,
3. Monthly summaries,
and
4. Supervisory nursing visit
notes.
C. If the
required recertification information is not received before the last certified
date, the hours from the last certification period up until the date of receipt
of the required documentation are subject to denial.
D. A PDN provider employing CNAs cannot bill
the beneficiary for hours when the provider failed to seek
certification/recertification in a timely manner.
Notes
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