Utah Admin. Code R414-40-4 - Service Coverage for Private Duty Nursing
(1) Private duty nursing services are a
limited benefit that is provided with the expectation that the member's need
for private duty nursing services will decrease over time.
(2) Medicaid covers medically necessary and
appropriate private duty nursing services for a limited time to provide skilled
nursing care in the home. Medicaid covers private duty nursing services while
the agency trains the member's caregivers to provide the necessary care. Once
the caregivers have been given sufficient training for the member's needs, the
private duty nursing services end. A member, however, who still requires more
than four hours of ongoing skilled nursing services may receive private duty
nursing services as provided in this rule.
(3) The number of private duty nursing (PDN)
hours that a member may receive is based on how the member scores on the PDN
Acuity Grid. The PDN provider shall provide supporting documentation to justify
the member's score. The PDN Acuity Grid must reflect the average daily care
given by the nurse during the previous certification period.
(4) After informing the member's family or
similar representatives who live with the member and in coordination and
consultation with the physician, the private duty nurse shall attempt to wean
the member from a device or service and identify new problems.
(5) Medicaid does not cover the following as
private duty nursing services:
(a) custodial
or sitter care to ensure the patient is compliant with treatment;
(b) respite care;
(c) monitoring behavioral or eating
disorders; and
(d) observation or
monitoring medical conditions that do not require skilled nursing
care.
(6) Medicaid does
not cover private duty nursing services if the services are available from
another funding source, agency, or program.
Notes
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