Dear Provider,
Thank you for your valued partnership.
Staywell and Children’s Medical Services (CMS) Health Plan would like to inform you of an update to prior authorization requirements for private duty nursing services. This is to align with AHCA’s Private Duty Nursing Services Coverage Policy (PDF) and Section 409.968(6), Florida Statutes requiring “ all covered and authorized home health services are provided to recipients”
Florida Medicaid private duty nursing (PDN) services provide medically necessary skilled nursing to recipients. Historically, Staywell and Children’s Medical Services (CMS) Health Plan would allow both service codes, S9123 (RN) and S9124 (LPN), to be requested simultaneously and for providers to claim for the actual service rendered.
Effective March 15, 2021, in order to align authorizations with members’ needs as directed by the Florida Legislature and the Agency for Health Care Administration, providers are required to submit authorization requests for PDN services with sufficient clinical information. This is to support the medical necessity for PDN services and the level of nursing care being requested, either an LPN or an RN as appropriate for the member’s individual health care needs. PDN authorization requests must only include one service code referenced above, unless the services do not overlap.
All PDN authorization requests are reviewed for medical necessity, and the level of service requested is either approved or denied based on the medical needs documented in the authorization request. If the authorization request is denied, providers will receive faxed notification of this determination and may appeal by contacting the Health Plan at 1-866-329-7651 to schedule a peer to peer review with our medical director(s).
We appreciate your assistance in providing exceptional care to our members.
If you have any questions, please contact Staywell Provider Services at 1-866-334-7927 and CMS Health Plan Provider Services at 1-866-799-5321.
Sincerely,
Utilization Management Department
