Ohio Admin. Code 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
children and adults
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.
(b)
(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:
(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.
(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
children and adults
individuals enrolled on an HCBS waiver administered by
the Ohio department of developmental disabilities
(DODD) or 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 DODD,
or 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
a DODD or
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
a DODD or
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 DODD or ODA case manager, as
applicable, in writing of the authorized amount, scope and duration of PDN
services and the PDN authorization number. The DODD
or 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
a DODD or
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
DODD or ODA case manager in writing of the
denial of the PDN authorization request. The DODD
or ODA case manager shall notify the PDN provider in writing of the
denial.
(3)
The provider shall notify ODM and the DODD
or 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 DODD
or 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.
(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.
(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
DODD or 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.
Notes
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.
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