20-561 Review New Requirements for Private Duty Nursing for Medi-Cal Members Under Age 21
This information applies to Physicians, Participating Physician Groups (PPGs), and Ancillary providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.
Case management/care coordination and prior authorization requirements apply to the health plan and delegated PPGs
This update outlines the responsibilities related to case management/care coordination services for private duty nursing (PDN) services for Medi-Cal members under age 21 pursuant to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. The health plan, with assistance from participating provider groups (PPGs) delegated to provide utilization management for such members, is responsible for case management requirements.
Get prior authorization
PDN services are nursing services provided in a member’s home by a registered nurse (RN) or licensed vocational nurse (LVN) for a member who requires more individual and continuous care than what would be available from a visiting nurse.1
Submit prior authorization requests for PDN services as indicated:
Providers participating through PPGs
Providers participating through a PPG must contact their PPG, follow the PPG’s prior authorization process and use the PPG’s forms.
Direct Network providers
Direct Network providers must request prior authorization by completing a Request for Prior Authorization form and faxing it to the health plan’s Health Care Services Department at 1-800-743-1655. Providers must submit clinically relevant information for medical necessity review with the prior authorization request. The form is available in the Health Net Provider Library under Forms and References.
For CCS-eligible conditions
When PDN services support a California Children's Services- (CCS-) eligible medical condition, the provider must submit a Service Authorization Request (SAR) with clinical documentation to the local CCS program office. CCS will authorize a SAR for the requested services if medical necessity criteria are met.
How to access prior authorization requirements
Currently effective prior authorization requirements are available on the Health Net provider website both pre-log in and post-log in.
If the provider is:
Then the provider should select:
Accessing the provider portal pre-log in…
Working with Health Net > Policies for Non-Contracting Providers > Additional Resources > Services Requiring Prior Authorization
Accessing the provider portal post-log in…
Working with Health Net > Contractual > Services Requiring Prior Authorization
PDN case management/care coordination responsibilities
When an eligible member under age 21 is approved for PDN services and requests that the health plan or delegated PPG provide case management services for those PDN services, the health plan or delegated PPG’s obligations include, but are not limited to:
- Providing the member with information about the number of PDN hours the member is approved to receive;
- Contacting enrolled home health agencies and enrolled individual nurse providers to seek approved PDN services on behalf of the member;
- Identifying potentially eligible home health agencies and individual nurse providers and assisting them with navigating the process of enrolling to become a Medi-Cal provider; and
- Working with enrolled home health agencies and enrolled individual nurse providers to jointly provide PDN services to the member.
Note, members approved for PDN services by delegated PPGs are identified via the delegated PPG’s monthly utilization management Authorization Request (AR) source data log submission. Fifteen days post log submission, the list of approved members is provided to the health plan’s Case Management Department to monitor care coordination.
Members may choose not to use all approved PDN service hours, and acceptance of available PDN services is at the member’s discretion. The health plan and delegated PPGs are permitted to respect the member’s choice. The member’s record must document instances when a member chooses not to use approved PDN services.
What’s required for PDN services?
- PDN services require an authorization for all members under age 21.
- If the PPG is delegated for utilization management, the PPG is responsible for completing the authorization.
- If the PPG’s member is receiving PDN services through CCS, CCS is responsible for the authorization.
- Whoever completes the authorization must document all efforts to locate and collaborate with providers of PDN services and with other entities, such as CCS.
- All members under 21 receiving PDN services must be case-managed.
- Providers must submit a referral to the health plan’s Case Management Department for members under 21 receiving PDN services approved by the PPG, and for their members receiving PDN services through CCS or another entity.
- Providers can submit a referral to the health plan’s Case Management Department by completing and submitting a case management referral form via email to CASHP.ACM.CMA@healthnet.com or by fax to 1-866-581-0540. The form is available in the Health Net Provider Library under Forms and References.
Health Net, on behalf of CalViva Health, is sending a notice to every member under the age of 21 for whom it has currently authorized PDN services on or before July 31, 2020. The letter describes case management services available, who is responsible for providing such services, how to access such services and more.
Monitoring and oversight of delegated PPGs
The health plan’s Delegation Oversight Department will monitor and evaluate your compliance to all requirements through the health plan’s annual compliance audit in the following areas:
- Review of EPSDT policies and procedures including:
- Approval of services that are medically necessary for EPSDT eligible members.
- Communicating the approval duration/number of approved services/hours if applicable.
- Assisting the health plan Case Management Department with case management and care coordination services for EPSDT members regardless of financial responsibility for services approved. If the PPG was not the entity to approve the services, the PPG is still required to assist with the provision of case management services as needed or requested by the member.
- Refer members for whom PDN services have been approved or for whom the PPG is aware have been approved by another entity (such as CCS) to the health plan's Case Management Department to monitor care coordination.
- Review of procedures for assisting the health plan’s Case Management Department with requests for PDN services including:
- Validation that the home health agency/provider of PDN services is enrolled as a Medi-Cal provider.
- Assisting the health plan Case Management Department with contacting home health agencies and enrolled individual nurse providers on the member’s behalf.
- Arranging for all PDN service hours, as needed or requested by the member.
- Documentation of all attempts to identify PDN services for the member and the member’s refusal to use all PDN hours approved.
- Evidence that the PPG is actively assisting the health plan to increase the network of private duty nursing services by:
- Assisting eligible home health agencies/individual providers to enroll as Medi-Cal providers.
- Assisting the health plan Case Management Department with leveraging home health agencies and individual nurse providers (in combination if needed) to meet members’ needs.
- Additional activities as identified
For more information on these requirements, refer to the provider operations manual or contact your assigned health plan Delegation Oversight compliance auditor.
The Department of Health Care Services (DHCS) All Plan Letter (APL) 20-012 dated May 15, 2020, outlines the requirements.
The health plan and PPGs delegated for utilization management are contractually obligated to provide case management/care coordination services to members. Specifically, for Medi-Cal eligible members under age 21 who have had PDN services approved, managed care health plans are required to provide case management/care coordination, as set forth in the health plan contract, and to arrange for all approved PDN services, whether or not the health plan is financially responsible for the PDN services.
Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on the Health Net provider website.
Providers are encouraged to access the Health Net provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 1-888-893-1569.
1 For more information, refer to Department of Health Care Services (DHCS) All Plan Letter (APL) 20-012.