New Process for Private Duty Nurses (PDN)Denials for Texas Medicaid

What’s new?
Implementation of a new process for handling Private Duty Nurses (PDN) denials and reduction for Texas Medicaid. Our Medical Director has to offer a chance for a peer-to-peer 24-hour pre-determination. Per the Uniform Managed Care Manual (UMCM) 3.22, we must offer an opportunity for a peer-to-peer consultation to the requesting physician no less than one business day before an Adverse Benefit Determination is issued.

What’s the process?
Following steps of impending Adverse Benefit Determination by our Medical Director:

• Outreach to the PCP or ordering physicians by our scheduling team to offer an opportunity for a peer-to-peer prior to determination.
• If the PCP or ordering physician rejects the opportunity or requests a peer-to-peer call more than 24 hours from the original call, the Medical Director will complete Adverse Benefit Determination at the end of the 24-hour period.
• Notification within five business days, the scheduling team will notify the PCP or ordering physician of the Adverse Benefit Determination and the opportunity to complete a peer-to-peer.

Questions
For questions or additional information, please contact:

• The BCBSTX Medicaid Provider Service Center at 1-877-560-8055
• Your Texas Medicaid Network team at 1-855-212-1615
• Submit via email Texas Medicaid Network Department.