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Private Duty Nursing for Children and Adolescents Under EPSDT Detailed

April 5, 2017

Private duty nursing (PDN) for children and adolescents under 21 years of age is available under the Medi-Cal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. To be covered under EPSDT, PDN must be medically necessary to correct or make more tolerable the child’s or adolescent’s physical or mental condition. The determination of medical necessity is made case by case, taking into account the needs of the individual child or adolescent.

The child’s treating physician is responsible for determining or recommending that PDN services are medically necessary. If the state’s expert disagrees with the treating physician as to whether a particular child’s service is medically necessary, the state is responsible for the decision based on the medical documentation provided. The child or the child’s family may appeal the state’s decision under the Medi-Cal fair hearing procedures.

In the past, a “level of care analysis” and “cost limit” were used to decide requests for PDN services under EPSDT, but that is no longer the case. Coverage of EPSDT PDN services is determined based on medical necessity for each case.

Requesting EPSDT PDN if enrolled only in a managed care plan
For EPSDT to cover PDN services for a child or adolescent enrolled in a Medi-Cal managed care plan, the provider must request PDN by submitting a request to the managed care plan. Each managed care plan has its own procedures for requesting services. Providers should contact the child’s managed care plan for that specific information.

Requesting EPSDT PDN through fee-for-service Medi-Cal
If a child or adolescent receives Medi-Cal services through fee-for-service Medi-Cal, the provider can request PDN services directly through the electronic Treatment Authorization Request (eTAR) system, and submit the necessary documentation by selecting “Submit Freeform Attachments.”

Requesting EPSDT PDN if related to a California Children’s Services eligible condition
If the requested PDN services relate to a California Children’s Services (CCS) eligible medical condition, the request must be directed to the EPSDT Unit. Eligibility is decided by CCS. If CCS denies the request on the grounds that the PDN services are not related to a CCS condition, the request can then be submitted to either the child’s managed care plan or through fee-for-service to determine if the services are covered under EPSDT.

Each Treatment Authorization Request (TAR) for PDN services must include the following documents:

  • PDN plan of treatment signed by a physician (within 30 days)
  • Nursing assessment (within 30 days of the requested date of service), and
  • Medical information supporting the nursing services requested, (that is, medication administration record, discharge summary notes, ventilator log, suction log and treatment notes)

For general information about EPSDT services, providers can visit the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Web page of the Department of Health Care Services (DHCS) website. The PDF document EPSDT– A Guide for States contains further information regarding EPSDT services, including but not limited to PDN.

Questions about coverage of PDN services under EPSDT can be directed to the DHCS Systems of Care Division, EPSDT Unit by phone at 1-855-347-9227 or by email at EPSDT@dhcs.ca.gov.