Provider Alert! Subject: Prior Authorization Guideline updates for Private Duty Nursing (PDN)

Attention: All Providers

Effective Date: March 1, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: TCHP would like to inform you of recent updates to the prior authorization requirements and the effective dates. Updates include the following:
Private Duty Nursing, effective March 1, 2021:

• Nursing notes, ventilator logs (if applicable), suction logs (if applicable), and seizure logs (if applicable) are no longer required. If not provided, these documents may be requested by TCHP if in the judgement of TCHP, these additional documents are required to adequately assess medical necessity for the requested private duty nursing services.
• The request can now be submitted within 30 days of end date of the current authorization.
• Effective March 1, 2021, the member needs a treating provider visit at least every year (or every 365 days). This requirement is waived during the COVID disaster declaration period.

How this impacts providers: Providers should follow the new prior authorization guidelines and submit the requests for coverage timely to ensure payment. The turnaround time for routine requests is three business days.

Next steps for providers: Update their office staff of the new authorization requirements.

Resources: 
Prior authorization form
TCHP prior authorization information

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.