• Provider Information
  • Introduction
  • Scope of Services
  • Services Provided by Registered Nurses
    • Introduction
    • Supervision of Delegated Tasks
  • Services Provided by Licensed Practical Nurses
  • Classification of Nursing Services
  • Wisconsin Medicaid Certification Requirements
  • Requirements for Providing Ventilator-Dependent Services
    • Introduction
    • Demonstration Renewals
    • Age-Specific Requirements
  • Changes in Certification
• Rights and Responsibilities
  • Introduction
  • Universal Precautions
  • Unacceptable Practices
  • Fees Prohibited by Wisconsin Medicaid
  • Private Duty Nursing Requirements
  • Emergency and Back-Up Procedures
  • Verifying Recipient Eligibility
    • Introduction
    • Limited Benefit Categories
  • Distribution of Medicaid Information
  • Written Statement of Recipient Rights
  • Contracts with Recipient and/or Family
  • Terminating Service to a Recipient
  • Recipient Responsibilities
    • Arrangements with Nurses in Independent Practice
    • Scheduling Providers
    • Freedom from Liability for Covered Services
• Covered Services and Related Limitations
  • Introduction
  • Private Duty Nursing Benefit
  • Recipient Eligibility for Private Duty Nursing Services
    • Introduction
    • Ventilator-Dependent Recipients
    • Recipients Who Are Not Eligible for Private Duty Nursing Services
  • Hours of Care That Qualify as Private Duty Nursing Services
  • Private Duty Nursing Services Reimbursement Requirements
  • Place of Service for Private Duty Nursing Recipients
  • Providing Disposable Medical Supplies
  • Coordination Services for Ventilator-Dependent Recipients
    • Introduction
    • Documenting Coordination Services
    • Reimbursable Coordination Responsibilities
    • Change in Coordinators
  • Coordination Services for Recipients Not Ventilator-Dependent
    • Introduction
    • Coordination Services Documentation
    • Coordination Responsibilities
    • Change in Coordinators
  • Case Sharing
    • Introduction
    • Provider Responsibility
    • Case Sharing Documentation
  • Reimbursement Not Available
    • Introduction
    • Travel and Record-Keeping Time
• Documentation Requirements
  • Introduction
  • Required Information for Medical Record
    • Introduction
    • Physician Signature
  • Documentation Requirements of Supervising Nurses
  • Availability of Records to Others
    • Introduction
    • Record Maintenance After Termination as Wisconsin Medicaid Provider
• Plan of Care
  • Introduction
  • Plan of Care Documentation Methods
    • Introduction
    • Submitting Another Format for the Recipient's Plan of Care
  • Obtaining Plan of Care Forms
  • Developing the Plan of Care
  • Physician's Orders and Signature
    • Introduction
    • Start of Care
    • Certification Period
    • Verbal Orders
  • Plan of Care Requirements
  • Medical Necessity and the Plan of Care
  • Changes to the Plan of Care
• Prior Authorization
  • Introduction
  • Responsibility for Prior Authorization
  • Services Requiring Prior Authorization
    • Introduction
    • Limits on Authorized Services
  • Requesting Private Duty Nursing Hours
    • Introduction
    • Hours of Private Duty Nursing for Children
    • Requesting Pro Re Nata Hours
    • Flexible Use of Weekly Hours
  • Required Documentation for Prior Authorization Requests
    • Introduction
    • Prior Authorization Request Form
    • Private Duty Nursing Prior Authorization Acknowledgment
    • Prior Authorization Attachments
  • Submitting Prior Authorization Requests
  • Prior Authorization Effective Dates
  • Prior Authorization Responses
  • Prior Authorization Backdating
    • Introduction
    • Initial Requests
    • Extraordinary Circumstances
    • Subsequent Requests Will Not Be Backdated
    • Returned Requests
    • Amendment Requests
    • Denied Requests
  • Amending an Approved or Modified Prior Authorization Request
  • Enddating a Prior Authorization Request
  • Out-of-State Private Duty Nursing
    • Introduction
    • Out-of-State Prior Authorization Request Requirements
    • Procedure for Obtaining Authorization for Out-of-State Travel
• Claims Submission
  • Introduction
  • Claims Submission Options
    • Introduction
    • Paper Claims Submission
  • Follow-Up to Claims Submission
  • Billing Across Midnight
  • Daylight Savings Time
• Codes for Prior Authorization and Claims
  • Introduction
  • Revenue Codes
  • Date of Service
  • Procedure Codes
  • Modifiers
    • Introduction
    • Start-of-Shift Modifiers
    • Professional Status Modifiers
    • Case Coordination Modifier
  • Units of Service
    • Introduction
    • Rounding Guidelines
  • Prior Authorization Number
  • Diagnosis Code
• Appendix
• PDF

 

 

Prior Authorization

Requesting Private Duty Nursing Hours

Hours of Private Duty Nursing for Children

To determine the hours of PDN care for children, providers should consider the extent to which the family and/or other unpaid caregivers are capable of providing medical cares.

Approval of PDN for 24 hours per day may be considered for children in the following circumstances:

• For short-term care after institutional discharge or after in-home exacerbations with significant medical changes, allowing time to teach the family or caregivers and to stabilize the child and develop routine care techniques.
• For short-term care if a single parent or caregiver is hospitalized or if one family member or caregiver is hospitalized and the other is not capable of providing care. Private duty nursing for 24 hours per day may fill the gap until other caregivers can be taught cares, or until the usual family member or caregiver can resume them.
• If the family or caregivers are not capable of providing any needed cares.

Private duty nursing may be approved for family member or caregiver work time. For example, if the family member or caregiver works outside the home, a reasonable number of PDN hours may be approved to allow for the family member or caregiver’s absence from cares for work and commuting to and from work.

If overnight PDN is medically necessary, PDN may be approved for family or caregivers’ sleep time. Private duty nursing may be approved for the night shift so the family or caregivers can sleep. Sleep time may be approved during the day if the family member or caregiver works during the night.

Private duty nursing may be approved for medically necessary services if the family needs time to perform family or other similar responsibilities of the family or caregivers such as grocery shopping, medical appointments, or picking up medical supplies.

Private duty nursing may be approved for the child’s school hours when it is medically necessary for a nurse in independent practice (NIP) to accompany the child to school. In many cases, the child meets Wisconsin Medicaid’s eligibility criteria for PDN, but is cared for at school by nurses’ aides or laypersons, with a school registered nurse (RN) available as needed.

When determining the number of PDN hours that will be approved, the following elements will be considered:

• The child’s school time.
• The family or caregivers’ work schedule.
• Any other pertinent information.

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