Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-12 - Ohio Home Care Program › Section 5160-12-02.3 - Private duty nursing: procedures for service authorization

Current through all regulations passed and filed through July 1, 2024
(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
			 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.
(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.
(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:
(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.