Private Duty Nursing Prior Approval FAQs (2025)

Table of Contents
1. What are the changes to the PA submission process for PDN providers? 2. Will the MUD form and Hourly Criteria form still be required? 3. How do we know what procedure codes to select? 4. After the initial 30 day approval, what documents are required to extend to 180 days? Note: PA cannot be granted until all required documentation is submitted. 5. For the initial request or shared case initial request that are both for 30 days, after 30 days is another PA needed? 6. Which type of requests requires attachments and which attachments are required? 7. Is it true that all new authorization requests must be submitted 10 days before the authorization end date? Does this mean the system will no longer allow prior authorizations (PAs) to be started earlier than 10 days before the end date? 8. When a patient attends school, we complete the school form, and consultants adjust PA units. Is anything being done to account for this in the PA process? 9. Can we still use the older forms, such as the 3061 or 3508, or are we now required to use the new forms? 10. Are there plans for providers to submit documents exclusively by uploading them, instead of mailing or faxing? 11. After submission of a PA, do we still need to email DMA? 12. Which NPI should be used: the requesting provider's or the PDN provider's? 13. Where will I receive decision letters and requests for additional information? 14. For attachments, is DMA-3172 and DMA-3173 still required since we are now entering caregiver work schedules directly into the requested information? 15. Will I still be required to upload all current PDN required documents even after entering additional information? 16. What is the timeline for PDN PA reauthorizations? 10 days or 30 days? 17. What should I do if I’m not able to obtain a doctor’s signature within the 30-day timeframe required for documentation? 18. How important is it to add all diagnoses in the PA request? Can we just add the primary in that section? 19. Do we need to submit a continuation request after an initial or transfer request? 20. Is there a quick reference that lists the status names and meanings? 21. How many days does it take to receive a decision on an initial request? Do we need to notify anyone about the initial authorization request? 22. For additional documentation that needs to be submitted for continuation of services and reauthorization, can we use the new Medical update form DHB 3509? 23. Do providers need to wait for the PA to post before providing requested hours when hours are shared between agencies? 24. When school hours are covered at home, do we need to submit a new PA for every absence? 25. How should missed school hours be submitted in a PA? 26. How are CAP-C retro authorizations handled? Sometimes by the time the provider knows there has been a change in coverage between CAP-C and Medicaid Direct, several PAs would need to be submitted to cover the entire time period. 27. How are managed care transfer authorizations handled? 28. Who should be listed as the rendering provider: the ordering provider or the agency rendering services? 29. Are the required forms still the same (3062, Hourly Criteria, 3171, Work Verification)? 30. If a PA is in pending status and a change occurs, should I wait for approval or update the pending PA? 31. Will there be a new PDN checklist available? 32. What is the purpose of the Request for Additional Information 10 business days and why do we not get the start date we requested? 33. What should I do if I get an error message while I am submitting a PA? References
You are here:
  1. Home
  2. Providers
  3. Prior Approval
  4. Private Duty Nursing Prior Approval FAQs

This list reflects answers to frequently asked questions regarding Prior Approval (PA) for Private Duty Nursing (PDN).

Updated Jan. 17, 2025

  • 1. What are the changes to the PA submission process for PDN providers?

    • No email or calls to DHB when PA or documents submitted. GDIT reviewers can see all submitted PA requests in NCTracks.
    • PAs for each service type, increases in hours, missed school visits, etc.
    • Request for Additional Information and Adverse Decision Letters will now be visible in the message center, in addition to being mailed.
    • Criteria for the different PA types during PA entry.
  • 2. Will the MUD form and Hourly Criteria form still be required?

    Yes, the policy still requires the upload of both forms.

  • 3. How do we know what procedure codes to select?

    Procedure codes can be found on page 29 of Clinical Coverage Policy No: 3G-1 and page 24 of Clinical Coverage Policy No: 3G-2.

    All beneficiaries:

    HCPCS Code(s)Program Description
    T1000PDN Nursing Services

    Beneficiaries Under 21 years of age:

    HCPCS Code(s)Program Description
    S9123Congregate Nursing Services, RN
    S9124Congregate Nursing Services, LPN
  • 4. After the initial 30 day approval, what documents are required to extend to 180 days? Note: PA cannot be granted until all required documentation is submitted.

    By Day 30

    • Attending physician-signed CMS-485 (Home Health Certification and Plan of Care Form)
    • Employment verification documentation (see page 10 of Clinical Coverage Policy No: 3G-1)
    • PDN service provider’s consent to treat document.
    • The Verification of School Nursing form, if applicable

    For Beneficiaries Over 21 years of age, every 60 days (By Day 60 and Day 120)

    • DMA-3509 (PDN Medical Update Form) and
    • Attending physician-signed CMS-485

    For Beneficiaries Under 21 years of age, every 60 days (By Day 60 and Day 120)

    • Attending physician-signed CMS-485
  • 5. For the initial request or shared case initial request that are both for 30 days, after 30 days is another PA needed?

    Yes, a new PA with Service Type CONTINUE will be needed.

  • 6. Which type of requests requires attachments and which attachments are required?

    Temporary requests to decrease the amount, scope, frequency, or duration of services for seven (7) days or less, such as over a holiday when additional family members are available to provide care and services, do not require NC Medicaid approval. A new PA and attachments are not required for Temporary Decreases.

    For a list of required attachments and documentation, please refer to the PDN Clinical Coverage Policies. Please remember that DHB PDN nurse consultants do not need to be notified by email when a PA has been submitted. NCTracks will notify the PDN Review Team of new submissions.

  • 7. Is it true that all new authorization requests must be submitted 10 days before the authorization end date? Does this mean the system will no longer allow prior authorizations (PAs) to be started earlier than 10 days before the end date?

    The system will accept PAs submitted before the 10 day mark. Please refer to Clinical Coverage Policy No: 3G-1 and Clinical Coverage Policy No: 3G-2 for specific authorization submission timelines.

  • 8. When a patient attends school, we complete the school form, and consultants adjust PA units. Is anything being done to account for this in the PA process?

    The PDN provider will need to submit new PA if hours are changing. A new PA for Missed School Visits should be submitted monthly using Service Type INCREASE.

  • 9. Can we still use the older forms, such as the 3061 or 3508, or are we now required to use the new forms?

    Until further notice, GDIT will accept forms as long as they are correct and complete regardless of if they are the newer or older version.

  • 10. Are there plans for providers to submit documents exclusively by uploading them, instead of mailing or faxing?

    All submissions for the PA type must be submitted electronically through the NCTracks Provider Portal.

  • 11. After submission of a PA, do we still need to email DMA?

    No, you will not need to email DMA. All PAs will be submitted and tracked in NCTracks.

  • 12. Which NPI should be used: the requesting provider's or the PDN provider's?

    The PDN provider’s NPI should be used.

  • 13. Where will I receive decision letters and requests for additional information?

    After July 29, 2024, decision letters and requests for additional information will be available in the Message Center inbox.

  • 14. For attachments, is DMA-3172 and DMA-3173 still required since we are now entering caregiver work schedules directly into the requested information?

    Both documents will still be required to be uploaded into the prior approval (PA).

  • 15. Will I still be required to upload all current PDN required documents even after entering additional information?

    Yes, all of the current PDN required documents with the appropriate signatures must be uploaded.

  • 16. What is the timeline for PDN PA reauthorizations? 10 days or 30 days?

    The 10-day timeframe is a general guideline for submitting reauthorizations. However, PDN has specific timelines that providers must follow, as outlined in Clinical Coverage Policy No: 3G-1 and Clinical Coverage Policy No: 3G-2. For beneficiaries over 21 years old, reauthorizations are due at least 15 days prior to the end of the current approved PA period. For beneficiaries under 21 years old, reauthorizations are due at least 30 calendar days prior to the end of the current approved certification period.

  • 17. What should I do if I’m not able to obtain a doctor’s signature within the 30-day timeframe required for documentation?

    As GDIT is contractually required to render a decision within 5 business days, PAs cannot be “held” for 30 days. If documentation is missing, GDIT will send a Request for Additional Information letter detailing what items are missing or what criteria needs to be met. The provider will have 10 business days to submit the additional information before the PA request is denied. PA is granted starting the date that all required documentation is submitted and all required criteria are met.

  • 18. How important is it to add all diagnoses in the PA request? Can we just add the primary in that section?

    Although the primary diagnosis is the most important to add during PA Entry, the best practice is to add the primary diagnosis and at least two supporting diagnoses. Documentation submitted should include all diagnoses.

  • 19. Do we need to submit a continuation request after an initial or transfer request?

    Yes, a continuation (Service Type CONTINUE) request will be required after an initial provisional or transfer provisional request.

  • 20. Is there a quick reference that lists the status names and meanings?

    StatusDescription
    1- Pend Al 1Pending Alert 1; request is incomplete and request for additional information issued
    A – ApprovedRequested procedure code and units are approved
    D – DeniedService is denied as requested; no services are approved
    M – ModApprovModified Approved; the requested service is approved but with a different procedure code to more accurately reflect the actual service
    P – PendingEPSDT or Adult Consult Request. The request has been sent for physician review.
    R – ReductionApproval of services issued for units less than requested
    S – SuspendedPA has been submitted and received in NCTRACKS
    T – TerminatedBeneficiary has transferred to managed care PAs.
    V – VoidPA has been voided by the provider or by the review staff.
  • 21. How many days does it take to receive a decision on an initial request? Do we need to notify anyone about the initial authorization request?

    GDIT has 5 business days to render a decision on all PA requests. If a request for additional information was rendered, providers have 10 business days to respond. If a request is sent for EPSDT or physician consult, GDIT has 15 business days to render a decision.

    Providers do not need to email or call to alert GDIT staff that an initial authorization has been submitted. GDIT staff can see all PA requests in NCTracks.

  • 22. For additional documentation that needs to be submitted for continuation of services and reauthorization, can we use the new Medical update form DHB 3509?

    Until further notice, GDIT will accept forms as long as they are correct and complete regardless of if they are the newer or older version.

  • 23. Do providers need to wait for the PA to post before providing requested hours when hours are shared between agencies?

    No, GDIT does not want our beneficiaries to lack any of their much needed services, the expectation is that the beneficiary will receive services while the two agencies are submitting for PA. Providers are expected to adhere to all policy requirements including submitting required documentation at least 5 business days prior to the requested start of care date.

  • 24. When school hours are covered at home, do we need to submit a new PA for every absence?

    Providers will need to submit a new PA each month to get the hours covered at home due to school absences.

  • 25. How should missed school hours be submitted in a PA?

    Monthly PA for missed school hours should be dated from the beginning of the month to the end of the month being submitted (e.g., the month of March=03/01/2024 to 03/31/2024). The hours missed that were covered by in-home PDN services will be reviewed in the new PA (INCREASE request). The original PA will not be adjusted. The number of hours requested equals the number of hours missed from school.

  • 26. How are CAP-C retro authorizations handled? Sometimes by the time the provider knows there has been a change in coverage between CAP-C and Medicaid Direct, several PAs would need to be submitted to cover the entire time period.

    Providers will need to submit PAs for whatever dates need approval along with the CAP-C approval letters for those timeframes. If more than one reauthorization period, providers will need to submit a PA for each one. Additionally, adding a brief memo stating that the beneficiary transitioned from CAP-C to Medicaid Direct helps the reviewer to understand why retro authorization is needed.

  • 27. How are managed care transfer authorizations handled?

    Each night, the approvals for beneficiaries that have transferred between Medicaid Direct and managed care are sent over. NCTracks creates a PA for those PAs that are sent to us by managed care agencies.

    If a provider finds out that a beneficiary has been transferred back to Medicaid Direct after receiving managed care approval, the provider should submit a new PA and include the managed care PHP approval letter. PA will be granted from the date the beneficiary became Medicaid Direct eligible to the end of the approval period on the managed care approval letter.

  • 28. Who should be listed as the rendering provider: the ordering provider or the agency rendering services?

    It is the PDN agency rendering the services.

  • 29. Are the required forms still the same (3062, Hourly Criteria, 3171, Work Verification)?

    The forms required in policy have not changed. Please refer to Clinical Coverage Policy No: 3G-1 and Clinical Coverage Policy No: 3G-2.

    Until further notice, GDIT will accept forms as long as they are correct and complete regardless of if they are the newer or older version

  • 30. If a PA is in pending status and a change occurs, should I wait for approval or update the pending PA?

    You have two options:

    1. Void the pending PA and submit a new one with the changes.
    2. Submit a separate PA for additional hours or changes while waiting for the original PA to be approved.
  • 31. Will there be a new PDN checklist available?

    DHB will not update or create a new PDN checklist. Providers should use the PDN Clinical Coverage policies as guidance.

  • 32. What is the purpose of the Request for Additional Information 10 business days and why do we not get the start date we requested?

    The 10 business days are the number of days you have to submit information before the PA is auto-denied. Per Section 5.1 Prior Approval, “Medicaid shall require prior approval (PA) before rendering Private Duty Nursing (PDN) Services.” and Section 5.2.1 General. “The provider(s) shall submit to the Department of Health and Human Services (DHHS) Utilization Review Personnel the following: a. the prior approval request; and b. all health records and any other records that support the beneficiary has met the specific criteria in Subsection 3.2 (over 21)/3.3 (under 21) of this policy.” Therefore, the start date of the PA is the date that all required documentation is submitted and all criteria are met.

  • 33. What should I do if I get an error message while I am submitting a PA?

    Take a screenshot of the error message and upload the screenshot along with the required documentation when you are able to create a PA.

Private Duty Nursing Prior Approval FAQs (2025)

References

Top Articles
Latest Posts
Recommended Articles
Article information

Author: Manual Maggio

Last Updated:

Views: 5802

Rating: 4.9 / 5 (49 voted)

Reviews: 88% of readers found this page helpful

Author information

Name: Manual Maggio

Birthday: 1998-01-20

Address: 359 Kelvin Stream, Lake Eldonview, MT 33517-1242

Phone: +577037762465

Job: Product Hospitality Supervisor

Hobby: Gardening, Web surfing, Video gaming, Amateur radio, Flag Football, Reading, Table tennis

Introduction: My name is Manual Maggio, I am a thankful, tender, adventurous, delightful, fantastic, proud, graceful person who loves writing and wants to share my knowledge and understanding with you.