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California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more
California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

20-562 Review New Requirements for Private Duty Nursing for Medi-Cal Members Under Age 21

Date: 07/29/20

Case management/care coordination and prior authorization requirements apply to CHWP and delegated IPAs

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. California Health & Wellness Plan (CHWP), with assistance from independent practice associations (IPAs) 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 IPAs

Providers participating through an IPA must contact their IPA, follow the IPA’s prior authorization process and use the IPA’s forms.

Direct Network providers

Direct Network providers must request prior authorization by completing a Prior Authorization form and faxing it to the CHWP Health Care Services Department at 1-866-724-5057. The form is available on the provider website under Provider Resources > Manuals, Forms and Resources.

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.

PDN case management/care coordination responsibilities

When an eligible member under age 21 is approved for PDN services and requests that CHWP or the delegated IPA provide case management services for those PDN services, CHWP or the delegated IPA’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 IPAs are identified via the delegated IPA’s monthly utilization management Authorization Request (AR) source data log submission. Fifteen days post log submission, the list of approved members is provided to CHWP’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. CHWP and delegated IPAs 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 IPA is delegated for utilization management, the IPA is responsible for completing the authorization.
    • If the IPA’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 CHWP’s Case Management Department for members under 21 receiving PDN services approved by the IPA, and for their members receiving PDN services through CCS or another entity.
  • Providers can submit a referral to CHWP’s Case Management Department by completing and faxing the Case Management Referral Form to 1-855-556-7909. The form is available on the provider website under Provider Resources > Manuals, Forms and Resources.

CHWP 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 IPAs

CHWP’s Delegation Oversight Department will monitor and evaluate your compliance to all requirements through the CHWP 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 CHWP Case Management Department with case management and care coordination services for EPSDT members regardless of financial responsibility for services approved. If the IPA was not the entity to approve the services, the IPA 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 IPA is aware have been approved by another entity (such as CCS) to CHWP’s Case Management Department to monitor care coordination.
  • Review of procedures for assisting CHWP’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 CHWP 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 IPA is actively assisting CHWP 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 CHWP 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 CHWP provider manual or contact your assigned CHWP Delegation Oversight compliance auditor.

Background

The Department of Health Care Services (DHCS) All Plan Letter (APL) 20-012 dated May 15, 2020, outlines the requirements.

CHWP and IPAs 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 CHWP contract, and to arrange for all approved PDN services, whether or not CHWP is financially responsible for the PDN services.

Additional information

Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. The provider operations manual is available in the Provider Resources section of the California Health & Wellness provider website. If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.

 

1 For more information, refer to Department of Health Care Services (DHCS) All Plan Letter (APL) 20-012.