• 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

Flexible Use of Weekly Hours

Flexible hours allow PDN recipients and their families to use authorized hours of care over an extended period of time. Hours may be used in varying amounts over the approved period of time to meet the needs of the recipient and his or her family. Flexible hours might be used in situations in which a primary caregiver is unable to provide as many hours of care as usual due to an acute illness. Even though flexible use of hours may be approved, the hours must still be medically necessary. Any PDN hours used over those hours approved in the flexibility period are not reimbursable by Wisconsin Medicaid.

Flexibility of hours can be requested to be used in week-long blocks of time. The most common blocks of time are periods of 1, 2, 4, 6, 8, and 9 weeks. Nurses should develop a record-keeping system to keep track of the hours of care used. This will help to prevent exceeding the number of hours approved in the period in which flexibility has been authorized.

One suggestion for tracking use of hours is to use the certification period in Element 4 of the Prior Authorization/Home Care Attachment (PA/HCA), HCF 11096 (fillable PDF, 139 KB).

Any time flexibility is requested, the date that each flexibility period starts must be clearly specified in the POC (Element 15 of the PA/HCA).

Requesting Flexible Use of Hours

To request flexibility in the use of PDN hours, recipients and their families should discuss the following with the NIP and physician:

• Hours of medically necessary care required.
• The time period in which flexibility will be used.

For example, if it is determined that up to 16 hours per day for seven days per week for a total of 112 hours per week of PDN services are required and the hours will be used flexibly over an eight-week period, the request would read as follows:

Private duty nursing RN/licensed practical nurse (LPN) up to 16 hours per day, seven days per week (total of 112 hours per week). Hours to be used flexibly, one to 24 hours per day, not to exceed 896 hours in an eight-week period all providers combined.

Refer to Appendix 5 of this handbook for an example of requesting flexible hours.

Amending Prior Authorization Requests to Include Flexible Hours

If an existing PA request has been approved without flexibility and it is determined that the use of flexible hours would be of benefit, providers should request an amendment to the PA request and obtain new orders from the physician. The amendment must explain the reason flexibility is needed and include the specific date that the use of flexible hours will start.

If a change occurs in the recipient’s medical condition or a family medical crisis arises (e.g., the extended illness of a primary caregiver), and the coverage for these events cannot be accommodated within the authorized use of the flexible hours during the flexibility period, nurses should submit a request for additional hours through an amendment to the original PA request. The amendment must explain the reason for the additional hours in detail; however, most events can be accommodated through the use of flexibility.
 

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