CARE PRO Pediatrics Family Care. Date: 71 l/Lb Client Name: MW MedicalRecordNo. ball) . Cleaning and Maintenance *?Document each task performed with time and .- - Time Initials Time Initials Suction Canister Cleaned 57% ?g Catheter Changed Suction Catheter Changed .- ?fth) Bathwed Shower ]Tub . H333 Suction Tubing Changed [6 Cleaning Solution Changed. . Nebulizer Tubing Changed 'E?uipment Cleaned [1.1/20 Nebulizer Filter Changed Linens Changed (per PCG scheduled) Oxygen Tubing Changed Travel Bag Restocked Ventilator Tubing/Circuit Changed Supplies Restocked Feeding Bag/Tubing Changed Trash Emptied Ostor'ny Bag Changed Client Area Cleaned ?256 5?52) dd I, Nursing Narrative Documentation All changes in your client's status Wei ?N?e?k?D-a left NumeN Pt. PCG/Other Signature. -1: care of/ Reported off to: Nurse Sigh I MM LA MD Reviewed by: White Medical Record Yellow - Patient Record 4of4 be detailed. Be sure to sign out at bottom of your narrative with signature included. ?Is?622?. We?) 0W LVN LPN (Circle One) LE FM DICAL NECES ITV Dashon Morris, DOB -- 5/2/2015, Medicaid -, requires PDN skilled nursing of 168 hours per week. 1:1 ratio due to his medical necessity of a tracheostomy and needing skilled tracheal suctionlng. Dashon is requiring tracheal sectioning on an average of 2-7 times per hour, this is required for him to sustain life. This need changes and increases as'l'ils secretions increase and become thicker, without his requirement of ongoing and frequent skilled assessment and skilled interventions. Delaying this skilled intervention causes imminent risk to health status due to medical fragility and increases risk of death. Dasth also has other medical needs of medication administration, administration and Interventions to any SE to his changed formula and dosages, skilled assessment of new and changed medications, administration of respiratory treatments and assessment of client response/ tolerance of treatment. IPV administration and response of intervention, as well as his skilled nursing orders in his 455. Dashon also needs assessment of safety and Immediate skilled interventions when he pulls his out. Immediate skilled intervention is needed when pt becomes decannulated end is hypoxia and needs immediate ambu beg/CPR interventions to sustain his life. Dashon's respiratory status is not stable due to the frequency of his tracheal suationing and sell decannuiatlon needing immediate intervention. medical necessity demands require 1:1 skilled nursing. MD Center for Foster Care Excellence Reads"? 935 Medical District Dr. Dallas. TX 75235 P: 214-455-5517 F: 214-455-3741 T-SBZ Fw944 unuulen'a Menlcal Canter 214-Aufi-em'1 g3 Car-e Pro Pediatrics 2700 W, Pleasant Run Rd. #380. Lancaster, TX 75146. Phone: 972-230-4747, Fax 972-230-4746 Website: PHYSICIANS TELEPHONBNERBAL ORDER Jul! muwu I was run w-Io- IO vane TO: DR. @121 ROMAN DATE: (Nnme of Physician) FROM: SEAIQNJN PATIENT: DASHON MQRRIS ,1 MEDICAID 13.0.3: 9.5% PATIENT FOR PNVATB DUTY SERVICES HPTO 163 FOR I (manna-non PERIOD 'Nursing Addendum to Plan of Care of 10 Prior Authorization Request Submitter?Certification Statement - I certify and af?rm that I am either the Provider, or have been speci?cally authorized by the Provider (hereinafter "Prior Authorization Request Submitter") to submit this prior authorization request. The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that they are personally acquainted with the information supplied on the prior authorization form and any attachments or accompanying information and that it constitutes true, correct, complete and accurate information; does not contain any misrepresentations; and does not fail to include any information that might be deemed relevant or pertinent to the decision on which a prior authorization for payment would be made. The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that the information supplied on the prior authorization form and any attachments or accompanying information was made by a person with knowledge of the act, event, condition, opinion, or diagnosis recorded; is kept in the ordinary course of business of the Provider; is the original or an exact duplicate of the original; and is maintained in the individual patient's medical record in accordance with the Texas Medicaid Provider Procedures Manual (T MPPM). The Provider and Prior Authorization Request Submitter certify and affirm that they understand and agree that prior authorization is a condition of reimbursement and is not a guarantee of payment. The Provider and Prior Authorization Request Submitter understand that payment of claims related to this prior authorization will be from Federal and State funds, and that any false claims, statements or documents, concealment of a material fact, or omitting relevant or pertinent information may constitute fraud and may be prosecuted under applicable federal and/or State laws. The Provider and Prior Authorization Request Submitter understand and agree that failure to provide true and accurate information. omit information, or provide notice of changes to the information previously provided may result in termination of the provider?s Medicaid enrollment and/or personal exclusion from Texas Medicaid. The Provider and Prior Authorization Request Submitter certify, affirm and agree that by checking ?We Agree" that they have read and understand the Prior Authorization Agreement requirements as stated in the relevant Texas Medicaid Provider Procedures Manual and they agree and consent to the Certification above and to the Texas Medicaid Healthcare Partnership (TMHP) Terms and Conditions. We Agree F00120 Revised Date: 02/01/2016 Effective Date 04i01/201 6 Nursing Addendum to Plan of Care (OCH--2 of 10 "Mme MORRIS Documentation Requirements All or the toliowing documents must be complete and received by Texas Medicaid Haahhizle Partnership (TMHP) berore review or authorization or PDN services can occur, 1. All components or the Nursing Addendum to Plan or care tccr>) completed and submited with 2' The Home Health Plan otcers (FOG) term, and 3. GOP Request Form (add crral maybe attached). El If the client is under 15 years or age. he/she must reside with an identified responsible adult/parentlguardieri who is either trained to provide nursing care, or is capable of initiating an identified contingency plan when the scheduled PDN is unapectedly unavailable, Name: Linda Badawo Relationship: Guardian Telephone: The dient has arr identified contingency plan. El The client has a primary physician who provides ongoing health care end medical superv ion. ill The placetsl where PDN services will be delivered supports the health and safely ottne client. El ll applicable. there are necessary backup utilities, communication. tie. and salety systems available and rurrctional. 1. care Plan Summary PDN services are based on a nursing assessment and nursing care plan established by the nurse proulderlrt collaboration with the physician, client, and tamlly. The nursing care plan provides a systematic wayto document care given, dlent response: to interventions, and progress toward the goals oflzre. Problem list: it) AI Risk rot sudden acute Respiratory Distress secondary to Respiratory System Disease (2) Gromr a. developmental alteration environmental deprivation/physical disability Altered ttutrilio - Less than body requirements related to dithculty with chewing swallowing and high metabolic needs (4) Al rislr tor impaired integrity related to iniesiwa device Goals 0' cars: (1) Patient will be tree Respiratory Distress end/ml illness (2) Patient will participate in developmental sumulatiorrs program/therapy to increase skills level Pt will receive nutrients needed tor normal growth; will show normal growth patterns tor height, weight. a physical parameers (4) Pattern will be free rronr all skin breakdowns. Specific measurable outcomes: (1) Fl will not be hospitalized due to rapiretory issues during this cert period (2) Ft will not decline in skill level during this can period (3) Pt will continue to maintain and not lose any weight this cert period. (4) Pt will not have any pressure wounds this can period. Progress toward goals: Pt continues to be high risk tor respiratory distress due in deoannulaling himself irequenfly. Pt continues to increase his movement with his extremities Ft has needed some feeding changes due to altered nutrition status Pt does not have any pressure wounds or skin breakdown at the present time but remains at high risk loririrpaired skin Integrity invasive devices Additlonal comments: Dasncn's immediate household consists othis foster morn/Primary Care Giver, Linda Eadawo, Destron's biological parents are not involved Dashon. Dashon also has a twin sister that tequila 168 hours of skilled nursing tor medical necessity Linda is unable to provide full therapeutic care for Dasrion and eppiea'ata the additional assistance Skilled Nursing has provided her. room Revised Dale: amt/2015 Emotive Date Mini/2915 Nurs Addendum to Plan of Care of 10 1. Summary of Recent Health History--For inltlal authorization or 90-day summary for extension of PDN services I lnotude resent hospitalizations, emergency mom visits. surgery (may submit a disotiaigs summary). illnesses, changes in condition. changes in medication or treatment. parent/guardian update, other pertinent observations nasnon was born prernatureiy and has a hx or bleeding in his brain as a result He has tranheostoniy. and is trash uxygenadependerii as well as gastrostomy-dapendenoe. DaShon's medical diagnoses indude: iratoiy distress Traoheostomy status, Gastrostomy status, Gastroasophageal Retlux Disease (GERD), grade 4 hemorrhage. chronic lung disease secondary to bronchooulinonary developmental delay, oommlsions. sip repair. esppnorla, oral phase Dasha" is on continuous oxygen therapy @025 - 2 LPM via trash Dashon is and reserves his nutrition and H20 llushes via his G-tube. He has had a in his iorrnula swliohlng him to Similac sensitive 20 Kosl tore HRS overnight via gb; simiiae 2o Koal via go 4x daity (total dose eedivlL) as wall as esomepraxole tumg od vie gb, sodium chloride 0 9% 1 vial via trash 4 hours and FRN. triamsinolons BID, sanna Bfimg 1/2 dd pin sonslipation. and sipmdsor 0.3% and dexamelitasone 0.1% BID to both ears 5 days Water Flush changed to 30 ml aiter eson read. Pi is learning to oeoome more active and is beooming hahniul to himseli in the process by pulling on his gb. hnie, and pulls his trash out iraouentty while his sister is requiring nursing oare. Dashon had a surgery on 7/5/16 and had bilateral tubes piaoed. reoently underwent an AER is being ieierred to anotier physician to address his trash stoma issues. Morn did not have the name availaola and stated that she was told that her that he vmuld probably have to have surgery on his trash stoma. Physician PCP Dr. Heidi Roman -August 4. 2016: last apple/20015 August 17. 2am-- Dsltas Em' and Audiology, Dr, Eric serg August 26.2016 - Dr. HuaysLin and Dr, Ellen Grishman at Children's Dallas Endocrinology June it. 2015 a Children's Dallas Gothalrnology and Presurgery Assessment Clinic June 21, 2016 a Dr. Geiiand at OCH 3. Rationale for PDN Hours--To either incmase. decrease. or stay the Simet Also address plans to decrease PDN hours. Requating 1.1 PDN or tea hrs/wk wiui nursing care Pt has iormula and med ohanges this past oan period. as well as requiring trash auctioning on an average oi2-7 times per hour PRN due to secreh'uns. Pt is teaming to move around and becoming more active and this sreates harm to himseli by his trash out. Pl has had to be amou bagged on several ooizsions per mom as a result oi him pulling his trash out while the nurse/FOG is providing skilled interventions with his sister. There hens oasn days that pt has pulled his traoti out more than onoe in a is minute period and averages at least stimes during a shin. Pi is pissing himself at high risk for as a result and at risk tor trauma to airway irom daosnnulation and irequent trash replaosmant Pt was seen by puimunsry, Dr. eetiands, oinoe on Size/ts and was documented that Dashon isn't very well from a respiratory standpoint, has issues with hypoxia and remains on resp 965 hours and reoeives every other skilled nursing is needed fur trash care. trash shangs, tiaoh svdioning, aspiration pretautions, assess and intervene with respiratory issues and hypoxia, 02 sets are to be monrtored 24 hours per day, pt requires respiratory treatments, opt and ipv treahnents, nutritional assessments due to resent nutritional changes and GERD, go ieeding interventions, assessment and interventions rotated to aspiraton with humidified trash mask while pt is sleeping, assess and maintain head being elevated as degrees. assess and imarvene to maintain sale above 92% and titrate 02 per pl's respiratory need. assas and maintain gb, assess plaoement and maintain ostloon inflation, assess ior s/sx or infecfign, amusioh, or dlslodgement, assess skin integrity 2 hours and plwide inoontinenoe care ireqvenlty to prevent skin reposition pt 2 hours to prevent pressure uloers. assess and monitor pain shirt and PRN, assess and instruct pog on educational issues as they arise, assess and intervene with stock oimedisailons and supptiss needed tor medical necessity, Dashon requires 1 nursing due to his increase in activity and high oi danger/respiratory hairn to himseliwith his ireouent trash desannulation despite eriorts tried to keep him irorn getting ahoid or it, hypoxia issues. and recent mad and nutritional changes. DaShon requires oonstant diligent monitoring with immediate interventions to manage his very iragiie medical condition and to avoid unnesossary hosphaltzations Dissharga to iarniiy under physician supervision Wflen goals are met and skilled oars no longer needed, PL oontinues to require skilled nursing tor his rnedioal tor as long as they exist Fnoizo Revised Dale: omit/2015 Etiutive Date M/oilzoits 2332:. <=nn 50 23--530>> .Q . .2222 5.32522252225 I 2.2.2.3: mime: 20:93 2.25 3 .o <2252.336 2.2le 232New.2. .52.. .2 .2. .52?53222: 2 a .. 5 {Sign .2 22 .2 2.2 3.8 a .eiagxi 2 5.526}: a 3.26.562: a 2 2. 2.. 2.. 822.5222.22.3.2: ?2,232.22. :2 53.32.. .. 2.. 2.. N. .N. .46<<223522.. 2262 2. .- .- 2. 62.2.62322.. 2.2. 2.. 2. .2. .22. 2.23.. 2. 2.2.. 2.62 in. 8.2.. n: 6.. .2: 2.: 2.. 2.. N5.. 2.. a. 2.. 2.. 2.. .23.. 22 EN. 3.3.. 2.62 2 2 5 5 ?222.62: 2. 6.25.2.2: 5.52.6.1.2.32.6". .253232 .2 2 2 ?232.22: 2 2 2.. 2.. .6. ?2.23: 16.22252: . EUR635: . EUR3.322.. 2.22.22.21..2. 22.622.52.63 2. .2 2.62.2.. 3.2. :4352225: 3.2.2.6232.2. 2.. 2.. 2.22:1? 3.3 .. fl .5223: 2. 25:22: 2. .2 2. a. 6.3.5.. 2.. 6. 2.2.2.E25223: 2 a. ?22263: 2 1.2.2.222: 2 .2 ?255.36 2 5.23.6.2: 2.. 2.. 2.. 2.. 2.. 2.. 2.. 862 .36 222.2% new 2-2.2 .120 tau 2.25.2.3 .25. :26 2.2.3: :20 2:25 :20 2.6 :5 2-0 :5 2R. Q-u bus--EL 223% 38.23.. .233. 23>uv=aa=umnm 23208233.. an: EUR58 .5 Egan; .222. Hum": "nuueu .025 ?20 .3223! .350 E2. umEgoo EH .5233 .uflquEE. mu: Esau 2:25. Zn; 3.2.2: ESE: .mfiholoau; Jougw 25." >=un .5979" $53.30 no wine--Em .q 2.8.223. "wig: <<22.35.222.225 SNER "flan maze: 20:93 2:5 OH #0 9.00 Eat 0- M5952 use I CARE PRO fliemName: mi Pediitvls Farme Care Media] Record No, . cleaning and Maintenance "'anment Each task perlorrned time and initials'" Tinre Initials Time initials Suction mnisrer Cleaned 1-8 I Catheterclranged Mfr>> simian cathetercnanged 301w aa'tir: med snawerl ITub 7 human Tubing managed r-fl [6r cleanlng Salutinn arranged Nebuilzer Tubing changed A) I Equipmentcleaned 1765 Nehuliler Filter changed . Linens changed (per PCG scheduled) 1/ Oxygen Tubing Changed Travel Bag Restade AW Ventilator Tuhlng/circull Changed supplies Resmcked Feeding Bag/Tubing changed 0755-} -- Trash Emptled I_ustor'ni, Bag Changed --Client Area cleaned Nursing Narrative Documentation $533; .4 Mix I All clranges in your elient's status must be detailed. ae sure ta sign out a! bonum or your narrative signature included. Ravi-remind}me a "weak fife" ea' Qampluewaisv vex as Mei/Mars meted! its Named--{w am cw um 'm gnaw It 51L [Mg Mm Tuna-a'RQdH SW Warsaw materialized Siemw we 9.3% ML moo cr-fque. a Mir-\flwukenk fi'genlflead--Ms genes osrel 7 fi/l'ej'r/S'; A4 amen in care di/Repdrted afrtoNurseNamegiAg/'H'Q (EMA RN7LVN LPN (circle one) Weviewedby: l' white - Medical Ream Vellnw Patient Reenrd 4 of 4 manna Pno Pediatrics Rt Famfly Care Medical Record No. cleaning and Mainrartance "'Docnmenl each task performed time and initials'" client Name: rune Initials Time Initials Suclion canister ueaned 0701) Catheter changed 1 /l suction Catheter Changed 67,51) gnaw: i i snower 1 Huh :1 049) Sualon Tubing Changed :1 in] ,i Cleaning Snlulion Changed Nehulilei Tubing changed 'Eauipnienx cleaned 3 manure: Filter (hinged linens Changed (per PCG scheduled) Oxygen Tubing cnanged Travel Bag Ventilator Tubing/Circuit Changed A, Supplles rimmed Feeding nag/Tubing Changed Trash Empued Oslomv Bag Changed firr Cliem Area cleaned Nursing Narrative Documentation All :hangs in your client's status must be detailed, Be sure to 51 use 'melsi honum divaur narrative signature included EMMA Maria A [km fwd-i set/"on mm," 'mm NMJ--swl; tam; mm hall "At wgifiz 48 hufifiw vgfikk: v-Qfiqr 9} 3:321me it 17--49 Revlewed b/ VWME Mudical Record 4 014 .e woman-731M \Zan mu reiiuw Patient Remd Wgex'heihbelfencw w'a *onzflexE r: fl" rum [Linn X,o 31' Whirligig", bi mic mmcfi' {$54431 . < Dale: I . g$?e239m ClienlNarlle- M0 I. Medical Renard No. deaning and Malmenance each wk performs?! with time and initial?" lime Illitlals lime Inllials swan deaned (71m 7s cemeterde I - sum'nn cetheter Changed b'lN meme: Shnwar ITuh I ,1on simian Tubing Changed Cleaning Salulinll manged I I Nebuliter Tubing changed 'EcTuipmentGeaned . I I Nehulizer Filter changed linens Changed (per PEG scheduled) I oxygen Tubing manged Travel Bag Renamed Supplijel mmcked Trash Emplied Venfilatnl' Tubing/Gram Changed Feeding dag/Tubing changed 05:an Bag changed Client Area cleaned i 9i i Q5 "dilatij Liam mmel it"; Vxfic, . zer." malls. with fiw . i am. . @526 MM. Pram -amd0e3m. Mn in care aI/Reporled off L4 NurseNamE' see Pl. PEG/Other signaiure: 5, while 7 Medical Remrd Vellow - Patient Record a of 4 Dara-4 1 Medical Record No. cleaning ind Maintenance "'Dncument Each Iask performed wim lime and inirials'" Time Initials rn-ne smion canlsrer Cleaned - 5 Commerciaan Suction Catheterchanged Bath: [fled shower 1 Hub IE Sunlon Tublng Changed A fleaning Soluuon Changed Luehulixer Tubing Changed 'rquipment Cleaned neoulixer Filter Oranged linens Changed (per scheduled) oxygen Tuoine Ulanged rmel Bag Restricted <1 Venularor Tubing/cl Changed Restacked Feedlng Big/Tubing Changed [Osmmy Bag Changed Trash Emptied Client Area cleaned Nursing Narrative nocumenmion must be derailed, Be sure (a sign nut at bottom of your narrative will! signature included . (rare ol/lleouned or: Nunerlamed' "ppm; gr @111 (Cravenel fr lae'C/orher Srgnarure MNM Renewed by While Medlcal Record Yellow rPaliem Record 40M Cm PilO ClienlName: Pediatrics fig Fimllv Care Medical new Cleaning and Mainlenance "'Document each task performed with 'ime and iniliflls'" Time nitials Tune lnilia s Cathetefchanged Bath: lBad I lShowef Huh Suctian Cinistel defined Suction Cantata! Changed Suction Tubing Changed cleaning Solution Changed Nebulizer Tubing Changed 'Efiuipmenlcleanzd u'nens Changed (per PCG scheduled) navel nag Rmdked suppnes Rammed Trash Empfied Chem Area deaned Nebulixev Filter changed Oxygen Yublng Changed Venti aml TuhlngICIrcuil Changed Feeding Bax/Tuhlng Changed Ostomy nag Changed changes in your cliznl's status must be detail Ho gun 35:ch .1 ggo ur \Auwt [Ea/vixen infare af/Repuned all C. 3W3 [If 1 "ax NurseSegnamre .xmn m'h'fiauewedby: inn; 7 CARE PRO Pediatrics Family Care CliemName: Medical Retard No.' . Cleaning and Mainlmance "'Dacumenl eadl task wim Klme and in 'als"' Time Initials 1inia Initials Suclinll Canister Cleaned Wm caineiercnangen mu Simian Catheter Changed My. Bath: [Bed Shower .lTub Suction Tublng Changed Mi 5 Cleaning Salutlon ChaugEd 41 'I'q Nebulizer Yubing Changed . a Hr uenulizer Fillev Changed I linens aianged (per PCG scheduled) F250 3c Oxygen Tubing oiangm Travel Bag Rmodred A Ventilami Tubing/Circuit Changed Supplies Resrocked 1550 Feeding Bag/whim; Oianged 1 trash Emptled 2; gag Osioinv Bag Changed Ellenl Area Cleaned 1945 i Nursing Narrative Documentallnn All changes in your client's slams must be delallEdV Be Sure to Sign out at [10an al your narrallve wim Signature Included, al- "303% 7 . V. *flmleflIntareoukepuled qua NurseName '3 24 22 7 LVN 9N(Cilt130m) FI. SignaluleL Reviewed'ul while 7 Medical Renard Yellow Pallem Record 4 014 PRO Pediauics Family Car 2 (lien! Mammw Ueaning and Maintenance "'Dacumerll each rask performed wirn lime and inifials'" 1 nme lnllials lime lninals simian Canister cleaned QM AD Carnerercnangea 41) Suctinu Catheter Changed I AD Bath: 1 Shnwer IYuh ii Suaiun tuning Changed Em cleaning Selurion changed IA 4 Nehuliner Tublng changed I Io'uipnrenmeaned (H) Nebullur filler Changed AD Linens Changed (per PCG scheduled] Oxygen Yubing changed ll 41) Travel Bag kesracked m) Venulamr manger: KM 90 supplies Reslocked AL Feeding sag/luhing Changed AD Trash implied 5L Osmmy sag alangea I A (H) clienl Area Cleaned m) Nursing Narranve Documentation All changes in your client's slams inns! he delailed Be sure lu sign our an honour afvoui narrative with signature induded. Ea" rams.le 113M Efcy- 3.9th mi: 14% lee A'h Age" ewe: <? (w "77 -- 5 Nurse Name 17w>> w. lionesignanne TL M7999 um (CirclP Onr'] in, signalure. M'Dr'r Wye-ewes hiw - Retold yellow 7 when 4 ol 4 Date: 5! 9'6 CARE Pno arentnane: Pediatril: Family Care Cleaning and Maintenance "'Dncurllent eatll task performed with lime and initials'" rima initials "me initials I Suctilm canister cleaned 135m 1-- Cathetercnanged Suction Catheter Changed mm natn: Haed 1 Shnwer i ITnb 3:1 Strain Yubing changed cleaning solution changed Tubing changed 'Ee'uinmenl cleaned mica--15% Nebulixer Filler aungad linens manged (per PCG scheduled) Oxygen Tubing cnanged navel Bag natodced ventilator tubing/Gram cnanged Supplies tweaked reeding flag/Tubing Dianged 1-5 Yrish Emptied fig 1 estamy sag changed client Area aeaned 13140 Jib Nursing Narrative Documentation All changes in your client's status must be detailed. Be sure to sign out at buttorn di your narrative with signature included. .t i 4 mm was Emmi: Wu? Twat. tr. rn Drew . US i P7 Caucusmg Tc WES/alumna v1 W-WAW mm; l>i wail HF: Hm yr gal 7-ng 1 Mg) LE 'rw Tn niilzg'l miAl ml Wauon Hug mm ,g'ymgg; a 2 ,1 pg: 215 7123;);702 it u, [1 PI left in (are al/Regurlad ur' in a . - 7112;" NquESrgr-alur'gihej'" fig" Pl PCG/Olhel Renewed hv While - Medical Record Yellow - Fallen! Record on LII Id tum us auum ruua mu uvu. encounter U313. 06/21, 016 -- MRN: 3799410 Dar?ell Descriptionliimontholdrnaie Of?ce Visit 6/2112016 Provider: Andrew S. Gelfand, MD (Pulmonology) Our Children's House Primary diagnosis: Gastrostomy tube dependent Physician Clinic Reason for visit: Trach Vent Dependent; Referred by Heidi Roman, MD Progress Nokes Colieen Parks. i?egistered Dietitian) Problem: Inadequate Oral Intake (NI 2.1) . Etiology: decreased ability to consume sufficient energy; history of mechanical ventilator dependent g-tube dependent Goal: Patient will receive adequate and appropriate food/nutrients Outcome: Progressing as Expected Intervention: Recommended Nutrition Interventions Nutrition Recommendations Meals/Snacks/PO Feedings - continue to offer stage 1 foods by mouth, as tolerated Enters! Nutrition - continue Similar: Sensitive 22 kcalloz (mixing 17 oz water 10 scoops of Similac Sensitive powder) - continue day feeds: 125 ml at 4 feeds; night feeds: 35 mllhourx 6 hours - continue current water flushes - 20-30 ml water flush after feeds, 30 ml water flush before and after night feeds, 10-20 ml water flush with medications, 2 timeslday continue to monitor weight trend and intake; if he continues to gain weight well and oral intake persists, then consider decreasing tube feeds Comments: NUTRITION FIE-ASSESSMENT, MONITORING, AND EVALUATION CLIENT HISTORY 13 mo. male seen during admissionrvisit dated 6121i16 (Unit/Clinic:OUR HOUSE PHYSICIAN CLINIC). Problem List: Patient Active Problem List Uiamoeis - Prematurity. 750- 999 grams 25- 26 completed weeks - Chronic lung disease - Gastroesophageai re?ux disease without esophagitis - Feeding by G-tube - Abnormal findings on newborn screening - Perinatal IVH (intraventricular hemorrhage), grade IV - Developmental delay . Tracheostomy status . Retinopathy of prematurity Convulsions Hearth care maintenance SIP PDA repair Esophona Printed by Latasha Thomas, MA at 7/14/ 16 4:25 PM Page 1 of 9 JUI (UH) UJIJU ?g/iti??lltg ., . I .. s, w; encounter Date: - - Oral phase - Failed newborn hearing screen - Hearing loss - Hypoglycemia, unspeci?ed Informant: Caregiver (comments) (foster morn) ANTHROPOMETRIC MEASUREMENTS Anthropometric Evaluation ls Growth Appropriate? Yes Areas of weight gain is appropriate since last visit; noted it is on the upper end of ConcemISummary: previous weight gain goal range; however, will wait to adjust TF as oral intake has just recently inoreased: if intake, weight gain. and growth continue, then will decrease TF at next visit Weight: 9.12 kg (20 lb 1.7 oz) (06l21l16 0946) Weight for Age Percentile: 19.81 Weight History: recent weight: 8.62 kg (5110116) Change: 12 gmlday weight gain 42 days Weight Goal: weight gain. 6-10 gm/dey until 1 1 months CGA Height: 66.4 cm (26.14") [06121116 0946) Height fer Age Percentile: 0 Weight for Length Percentile years): 98.44 Head Cerumference: 44 cm (17.32") (06121116 0946) Head Circumference for Age Percentile years): 2.74 NUTRITION-FOCUSED PHYSICAL FINDINGS (IF APPLICABLE) Overall Appearance: Well-nourished Gl Output: 1-2 BIWday; consistency varies based on food intake Urine Volume: good UOP reported FOODINUTRITION-RELATED HISTORY Diet Experience (if applicable) ?Home DietiBreastmilk/Formula: recently started taking more by mouth - now up to 2 times/day. stage 1 baby food rice cereal -Home Enteral Formula: Similac Sensitiive 22 kcal/oz (morn mixing 17 oz water 10 scoops Similac Sensitive powder) - 125 ml. 4 feeds/day, night feeds: 35 mllhOur 6 hours; receives 20-30 ml ?ush after day feeds: receives 30 ml water before and after night feeds; 10-20 ml water flush with medications. 2 timeslo?ay -Home Enteral Access: G-tub?e FOOD AND NUTRIENT INTAKE Intake Appropriateness ls Intake Appropriate? es . Areas of Similac Sensitive 22 kcalloz is age appmoriate; rice cereal and stage 1 baby ConcernfSumrnary: foods are also age appropriate Meali?SnackiPO Feeding Intake: stage 1 baby food mixed with rice cereal Enteral Intake: Similac Sensitive 22 kcailoz Printed by Latasha Thomas, MA at 7/14/16 4:25 PM Page 2 of 9 "373" I till) mt 'oili'irgl'bate: ml: 016 . vluvv- "wean" ls Intake Adequate? Nos raas oi rrent regimen appears adequate based on weight gain and growth Concern/Summary l" -Errergy Oral Energy Intake unlbl! It! cauculala based on report Entersl Energy intake 57 Keel/la; - 521 kcallouy Energy Naeas: minimum 57 521 ital/day Method ofEstlmatlng Energy Needs: Based on home feeds I weight lrend >Fluld Entaral Fluid Intake 95-102 ml aura/kg eru- 930 ml fluid/day no ml formula/day 10-20 ml flush with meditations BID 20-30 ml water flush day feeds 30 ml wily flush oeiore and after night feeds Fluld Needs: 55-100 ml fluidle I 775912 "ll fluid/day Method all Estimating Fluid Needs: Holliday - Sager Formula -Protein Oral Protein intake: unable to calmlata based on report Enteral Fmteln Intake: 1 2 gm pro/IQ 10.5 gm ova/day leeln Needs 1 2 gm 10.9 grrl/day Method lo! Estimating Protein Needs: DRI IA 5.7 Progress Notes rAbby ayrum Anderson new? (Nurse Practitioner) Nurse Practitioner by' Anew s. MD at snarzulo 9:46 PM Attestallun signed lry Andrew Gelfalid. MD at 9'48 PM (Updated) DaShon Darnell Morris was seen and examined with Abby Byrum Anderson. RN, PNP. I agree with the attached ventilator clinic note During the visit, DaShon underwent an extensive evaluation by multiple servroes, My assessment and recommendations renal: the impressions that were gathered and presented by the consulted services. More specifically, nutrition was consulted on this patient. Their recommendations have been implemented in the plan of care and discussed with the uretakar and/or parent. I consulted with respiratory therapy and reviewed ventilator settings and tracheotomy status The ease managerwas present. I reviewed the home care needs and status tor this patient. Radiological evaluation was done and the results reviewed Nursing obtained the requested laboratory tests. Results were reviewed. I reviewed the above information with the caretaker and/or parent as well as the team at this visit Time spent on direct patient care and medical management is graaterthan 70 minutes. Dashon Darnell Morris as a 13 in a male with history at chronic lung disease secondary to bronchopulmonary He has a trash but does not require chronic ventilation. He also has issues with hypoxia and Iyplcal!y is on halfa liter of oxygen Srnoe his last visit, he isnt very well from a respiratory standpoint. He has not had problems coughing or wheezing He has had good activity tolerance. He is gaining weight nioer with his present reading regimen. He remains on treatments every 6 hours. He receive: With every other treatment He is active making reas progress despite his giade 4 intraventnoular hemorrhage How ly does have some delays. That had any further episodes oi seizure. Overall, th how well he is dorng. At this trme, will not make any changes to his ca 3 were increased at his last visit We wr'l recommend seeing him in our private arged on ventilator clinic at this time We'll see him back in approximately He is followed by gastroenterology at Medical Center and they his nutrttion. Printed by Lstasha Thomas, MA at 7/14/16 4:25 PM Page 3 of9 Jut til min usm Ill ruusiuw I encounter Date: 56/21/2016 4- quthA II . Andrew Gelfand. MD. Pulmonary Visit Note Histog of Present Illness: DaShon is a 13 mo. male with a history of ex-25?26 weaker with complex past medical history including CLD with trach dependence, PDA sip repair. ROP, hearing loss, intrauterine drug exposure. with g-tube dependence, GERD sip Nissan, grade 4 NH. developmental delay. hydrocephalus s/p VPS. He presents to OCH today for his routine vent Clinic Visit. 1. Gastrostomy tube dependent 2. Chronic lung disease 3. PDA repair 4. Prematurity, 750-999 grams, 25-26 completed weeks DaShon presents today for routine vent clinic at Our Children's House on 6/21/2016. He has had no hospitilizationsvisits. . DaShon has had no recent illness(es). Trach is changed every week; with no dif?culty. . Type: Pediatric, Bivona, lexTend. . Trach Size: 3.5. Additional Information: (HTC at night). CPT is administered every 6 hours we DaShon is on the vent 0 hours per day; this is tolerated well (wear humidi?ed trach collar at night). DaShon is off the vent (completely off vent since October oi 2015) with HME. trach collar; this is tolerated well. Baseline O2 requirements are 0.5 of oxygen via trach. Currently requiring 0.5 of oxygen via trach. There is a moderate amount of thin and clear tracheal secretions. Tracheal mucus plugs are not present. Wheezing is not present. Increased coughing is not present. Trach Site: clean, dry. intact G-Button Site: dry. clean, intact, open to air Past Medical History Diagntosis . . - - . - Date . - 25-26 completed weeks of gestation 09/01/2015 Acidosis 05/02/2015 Acute respiratory failure 07/06/2015 - Bilateral inguinal hernia without obstruction or gangrene 09/10/2015 - Bronchopulmonary dyspiasia originating in the perinatal period 10/05/2015 Cardiomegaly 05/11/2015 Congenital anemia 05/02/2015 Congenital anomaly of heart 05/21/2015 Congestive heart failure 05/21/2015 . Developmental delay 09/01/2015 unspeci?ed 05/11/2015 Esophageal reflux 08/24/2015 - Feeding dif?culties and mismanagement 06/24/2015 Fitting and adjustment of vascular catheter 05/03/2015 Gastro-esophageal re?ux disease with escphagitis 10/04/2015 i-iX OTHER Hypoxemia 09/21/2015 - lntraventricuiar hemorrhage of newborn, grade 0! 05/03/2015 Jaundice 07/06/2015 Printed by Latasha Thomas, MA at 7/14/ 16 4:25 PM Page 4 of9 ?4 UJOJI II L??ounter Date: - Obstructive hydrocephalus 05/18/2015 - Ostium secundum type atrial septal defect 05/06/2015 Other chronic respiratory diseases originating in the perinatal period 07/23/2015 - Other forms of 05/03/2015 - Other intra-abdominal and pelvic swelling, mass and lump 07/21/2015 - Patent ductus arteriosus 05/03/2015 Periventricular leukomalacia 05/23/2015 Personal history of surgery to heart and great vessels, presenting 08/05/2015 hazards to health - Pneumonia, organism unspeci?ed 05/27/2015 - Pneumothorax, unspeci?ed 05/11/2015 - Primary apnea of newborn 05/15/2015 - Primary atelectasis of newborn 05/15/2015 - Pulmonary collapse 05/04/2015 Pulmonary congestion and hypostasis 05/02/2015 - Radiologic ?ndings of lung ?eld. abnormal 05/23/2015 - Redundant prepuce and phirnosis 09/10/2015 - Re?ux esophagitis 09/21/2015 Seizure disorder has VP shunt for hydrocephalus Stridor 07/26/2015 - Tracheostomy status 09/15/2015 - Transient neonatal thrombocytopenia 0510512015 - Twin, mate liveborn. born in hospital, delivered by cesarean delivery 05/02/2015 Unapeci?ed atelectasis of newborn 05/16/2015 \?ral pleurisy 05/06/2015 Past Surgical History Precast/is. . - Laterality pate Gastrostomy (or) 08/24/2015 Medical City Dallas - Tracheostomy (or) 08/15/2015 Medical City Dallas Hx other surgical history - Hx gastric fundoplication 8/15/2015 Medical City Dallas No family history on file. Social History Soda/"History Narrative - - - .t .. Currently in foster care. Lives in foster home with faster mom, Min sister and 2 other foster children. Immunizations: Up to date. Flu: Completed this season. Synagis: Completed Series. Review of Systems: Review of systems revealed the following in addition to those discussed in the HPI: Constitutional: negative Eyes} - negative Printed by Latasha Thomas, MA at 7/14/16 4:25 PM Page 5 of 9 tun .- ?Mala-avg. vqrugtaul.) Ud-Jl n?co?nter bate: Upli'i??llu? ENT: trach dependent ey; - negative Respiratory . I see 61: Imigtube dependent GU. . mouldske?letat' Skim . .- negative Name. edevelopmental delay crawling Rayon Enme 7 Hemefanc . . negative Feed kllergy: .- Seasonalkllergy negative Ventilator Settings: I I Vents'ettings 5110/2016 sweatizms Resp 02 - 02 Sat - 99 1"th TYPO Pediatric;Bivona Pediatric;Bivona;FlexTend Trach Size 3.5 3.5 Vent Comments Trach dependent only. (No Data) Physical Exam: Vitals: "062111639946 BP: 94/63 BP Sitting Patient Position: Pulse: 121 Resp: (936 Temp: 36.8 Weight: 9.12 kg (20 lb 1.7 oz) Height: 66-4 cm (26.14") HC: 44 cm (17.32") 303: Height <0.01 %ile (Z: -4.56) based on WHO (Boys, 0?2 years) length-for?age data using Vitals from 6/21/2016. Weight 19.81 We -O.65) based on WHO (Boys, 0-2 years) weight-for-age data using Vitals from 6l21/2016. Body mass index is 20.69 Normalized BMI data available only for age 2 to 20 years. G'ene?galt - awake and alert. well developed, well nourished: no acute I I II ladistress. happy and playful HEEINIT: I PERRL. scleree clear. no rhinorrhea and oral mucosa moist NEGK . II supple, without and tracheostemy is dry. . - I clean and intact; Vent Type: Pediatric. Bivona, FiexTend. Trach Size: 3.5. was Printed by Latasha Thomas, MA at 7/ 14/ 16 4:25 PM Page 6 of 9 . 5?2 cur??HAL Iu LUIU .1 I UJIUAILUTJ Encounter . normal chest cont" guration clearto auscultation symmetrical . no retractions or nasal ?aring and no stridor regular rate normal 31 normal 82 and no murmur K?s-soft. non?tender, normal bowel sounds, without EXT I. ?euro Pulmonary Outpatient Visit Data: Imaging: CXR stable with good lung volumes. chronic lung changes with prominent pulmonary vasculature. Medications: Current Outpatient Prescriptions (Edioatioit- -acetaminophen (TYLENOL) 80 mgIO. 8 Take 10 by mouth mL susp drops chlorothiazide (DIURIL) 50 Suspension nystatin (MYCOSTATIN) powder sodium chloride 0.9 nebu ESOmeprazole 10 mg I sen-no 8.6 mg tablet pediatric multivit?iron WITH IRON) 1,500 unit-400 unit-10 mg/mL solution triamcinolone acetonide (KENALOG) 0.1 crea cream simethioone (MYLICON) 40 mglO.6 mL drops budesonide (PULMICORT) 0.5 mg? _mL nebulizer suspension CALCIUM CITRATE PO) . albuterot (PROVENTIL. VENTOLIN) 2.5 mg 13 mL {0.083 neb solution Sig Dispense every 4 home as needed 2.2 mL (110 mg) by PER 240 mL TUBE route 2 times daily Apply 1 application topically daily . INHALE VIAL VIA NEBULIZER EVERY 4 HOURS AND USE AS NEEDED FOR SUCTION AND TRACH CARE (Patient taking differently: INHALE 1 VIAL VIA NEBULIZER THREE TIMES DAILY) 600 mL 1 Packet (10 mg) by PER so Packet TUBE route daily 4.3 mg by PER TUBE route daily as needed for Constipation 1 mL by PER TUBE route daily 50 ml. Apply 1 application topically 2 times daily 20 mg by PER TUBE route 4 times daily as needed for Flatulence Inhale 0.5 mg by nebulizer 2 times daily 0.2 mg daily 03in via G-tube Inhale 2.5 mg by nebulizer every 5 hours No current facility-administered medications for this visit. Printed by Latasha Thomas, MA at 7/14/16 4:25 PM [it - organomegaly, gastrostomy: dry. clean and intact and no [masses detected rashes. warm, well perfused "'ino clubbing and no cyanosis or edema appropriate for age "'V'Re?ti 10 Page 7 of 9 m?oust'et'bate?: 663172016 .J i Allergies: Review of patient's allergies indicates no known allergies. Impression: . . DaShon is a 13 m.o.male with a history of ex-25-26 weaker with complex past medical history including CLD with trash dependence, PDA sip repair. ROP. hearing loss, intrauterine drug exposure, with g-tube dependence, GERD sip Nissan, grade 4 NH, developmental delay, hydrocephalus sip VPS. He presents to OCH today for his routine vent clinic visit. Plan: 1. Dispense baby wipes. quantity suf?cient for 1 month. 2. Discharge to of?ce. Please call 972-566-6996 to make appointment for follow up. Follgw U2: DaShon Darnell Morris will Return in about 3 months (around 90012016). The above history. exam, impression and plan were formulated with Andrew S. Gelfand, MD, who was present during the clinic visit. Abby B. Anderson, Progress Notes . Henderson, RRT (Respiratory Therapist} Respiratory Visit Note Do they have an ambu bag? yes Do they have a mask present? yes Is it age appropriate? yes Does the ambu bag have a trach attachment? yes Do you have a key for the trach? no git-her Notes [a Physician Orders from IMAGED, ooc Instructions . . I . - Return in about 3 months (around til/2012016). 1. Dispense baby wipes, quantity suf?cient for 1 month. 2. Discharge to of?ce. Please call 972-566-6996 to make appointment- After Visit Summary (Printed 6f21i2016) Additional Documentation . . . II . Vitals: BP 94/63 Patient Position: Sitting) Puise 121 Temp 36.8 [98.2 Resp 36 (Abnormal) Ht 66.4 cm (26.14") Wt 9.(17.32") 6M1 20.69 kgirn2 Ftowsheets: Vitals, Fat! Risk Assessment, Ambulatory Screening, Vent Clinic History, Heaith History, Discharge Information, Ventilator Settings, Assessment Type, Client History, Printed by Latasha Thomas, MA at 7/14/16 4:25 PM Page 8 of 9 In? vdIUbl?vULJ nl'i??blihter Date: Vin/22172013 Anthropometric-s. Diet History, intake 8: Standards 1. intake Standards, Physical Findings. Nutrition Charge Information Encounter info: Billing info. History, Allergies, Detailed Rap-or! Media? Scan on 60.312016 3:52 AM by Latasha Thoma; MA Care Order EnCOLinter Information Encounter Information Qrdeifs Placed . CAPILLARY (Resonad 6l21l20-16,Abnorrnal) HOME CARE MEDICAL EQUIPMENT - OTHER HOME CARE MISCELLANEOUS - EXTERNAL HOME CARE CY Oth??i Orders Perfel'med . CONSULT T0 OCH CLINICAL NUTRTION Medication Changes As ofGI2?lI2016 10:01 AM None Visit Diagnoses . .. Primary: Gaetroston'w tube dependent 293?1 ChrOnic lung disease J98.4 SIP PDA repair 298.89, 28?.74 Prematurity. 750-999 grams. 25-26 completed weeks P0703 Ventilator dependence 299.11 Printed by Latasha Thomas, MA at 7/14f16 4:25 PM Page 9 of 9 Mil/o Superior Arm: Appeals Coordinator RE: DASHON MORRIS MEDICAID - DOB- 05/02/2015 Nursing note from 5/11/16, 0700 -- 1500 shift, reports that Dasnon was suctioned vla (rash times during this shift and pulled his lrach outZ nmes within a 15 Minute period Leiillu On 5/4/16, Superior faxed an authorization to Care Pro Home Health with the authorized period of 4/26/16 to 7/24/16 for 6120 Units; 119 hours/week U2 Modifier Ratio 2:1. During the above reported 7 shifts, Dashon required tracheal suctioning 233 times. DaShon also pulled his trach out 15 times during the above noted 7 shifts. These events happened at different times throughout the 24 hour period. DaShon?s twin sister also requires private duty skilled nursing of 168 hours/week. Due to the 2:1 ratio decided by Superior both DaShon and his sister have both been placed at risk due to not receiving the skilled 1:1 attention that they need. The medical consenter has not been able to work due to insurance denying the authorization that would allow the attention and skilled nursing care that the patients medical conditions require. The clinical documentation and treatment sheets for the above cited notes have been included. Quit Rachelle Seaton, RN cc: Medical Consenter, Linda Badawo Dr. Heidi Roman Dr. Andrew Gelfand Date: I CARE PRO ennui": Mo Pediatrics Family Cave Medial Remrd N0 Cleaning and Mainxenance "'Documem each task performed wm. um and lmfials'" Time Initials Sunion Canister Cleaned Ta Suainn where; Changed Sumun Tubing Changed nme Inisz catnerer changed Bath: lEBd 1 Shower I ITuh Dm cleaning Solution cnanged Mg. m) Equipment Cleaned - Unens Changed (per rca scheduled; gm Travel Bag Supplifi stlonked Trash Empfled Ciient Area Cleaned Nebulizer Tubing Changed Nehulizer Finer Changed Oxygen Tubing Changed Ventilator Tublng/Circuk Changed Feeding Bag/Tubing cnenged asramy Big Changes: I Nursing Narrative Documentauun GK \Mawkrt v, 25m: 72.3w>> a! @3443 [$3.13.qu I 4.4 we" 'bLud--J. 98.: 54+ em} rg/'W -- "nan - mew-Lew 4a; pequ $4"ng Mflqew' 2?an+ )3ng 2141:: 31M awake r; WI 5 sq. rut-k 'u seafls We get or a 351- am- pawl an I and>> Wad L. < Appeal From nt to El! an appeal Mail 0: fax this completed (ban Supm'or Arm: Appeals Coordinator 2100 s' was, Sun: 200 Austin, TX 78704 le' 17866318-2266 Membcr Shag I 10:: Medjuid n: Name of person the appeal Egg be M: kg Relationship to Parent 7153.1 guardian/F05: Parent Fundy mambe: 'nna La at us: LOrher. coma" Phone "Whefl What semen was Dwedwm You can send us mm: informaan on you: use. Use the spit: haw ifyou want to send us more information. You can ma more sheets ifynu nut] to. Please Include a copy of the denial letter. Manila! ngnamfl of person Dam 5w,an 3375 3/19/15 Dashofl Morris DOB: 5/1/1015 Medicaid Appeal Regarding Authoritation a 0P0566150775 As stated in the nursan addendum, dated 7/6/2106, Pt has had some issues related to his trach stoma that will require surgery, had had medication changes, and formula changes, and requires tracheal suctioning on an average of 24 times per hour, 0n phone call with the Foster mom on August A, 2015, it was reported that pt now has even more required trach suctioning of 12-15 times per hour The reduction in hours and 2:1 ratio with U2 Modifier violates the Alberta C.F.R. 450.30, '1 U.S.C 1396d(r)(5), and Texas Healthy Steps The requested services are nursing services as defined by the Texas Nursing Practice Act and its implementing regulations; the requested services correct or ameliorate the Beneficiary's disability or physical or mental illness or condition; and there is no third party resource, as described in the Texas Medicaid Provider Procedures Manual, financially responsible for the requested services. The nursing services are to correct or ameliorate the Beneficiary/s disability or physical or mental illness or condition when the services improve, maintain, or slow the deterioration of the Beneficiary's health status. The BeneticiarYs medical needs have not decreased, as documented by the prior authorization request, therelnre, the Agech should nut have denied or reduced the amount of nursing services on the basis that the Beneficiary/s Condition or health status is "Stable" or has not changed. Superior failed tn follow the Alberta N. processes of Section 4, as well as failed the process cl pairing on the 2:1 decision for the Beneficiary. On a phone Call ll'om August 5, 2016, Superior staff concurred that the Beneficiary needed more hours and they did not realize the extent of the Beneficiarv's condition as they referred to the prior authorization request/appeal riled on 5/11/2016. Sr Medical Director, Dr. erendie Glamb, also stated that he had not even seen any paperwork for the other Beneficiary that they had planned on pairing the 2:1 ratio with, it was also stated an phone call irorn August 4, 2016, that the patients diagnosis did not warrant the amount ornursing hours and Dr. slomb thought that home health would suffice instead of private duty Alberto Nu Section 2.10 states that the Agech (Superior) will not arbitrarily deny authorization of nursing services or reduce the number at requested hours or services based solely upon the diagnosis, type of illness, cir condition of the Beneficiary. 42 us c. tassalam, 42 an. Alberto Ill, sReauestS for medically necessary Home Health Skilled Nursing services, Private Duty Nursing sewices, or Personal (are Services Will be prior authorized with reasonable promptness to ensure timely access to these Medicaid benefits For the purposes of this Agreement, prior authorization determinations for Home Health Skilled Nursing services. Private Duty Nursing services or Personal Care Services will be completed by the Agency or its Contractor within three (3) business days of receipt of a complete request. 42 U.S.C. 13963(a)(8); 42 C.F.R. 435.930, Beneficiary was not even given his due process during the last authorization/certification period of 4/18/16- 7/24/16, as there was a very long delay in obtaining authorization even though the required authorization forms were in the care of Superior. This delay in authorization denied the Beneficiary his right to a fair hearing due to the authorization being issued 17 days after the authorization/certification period, then the appeal and waiting for that decision before a fair hearing could be scheduled. We are now back with the same process in the fact that the correct authorization with the requested authorization dates were not sent by superior until 8/15/16 when the current authorization/certification period began on 7/17/16. Dashon requires tracheal suctioning as needed every hour to ameliorate his condition as afforded to him within the Texas Healthy Steps which would require a skilled nurse to be available 168 hours per week; 1:1 ratio as requested. These hours also include the issue of the Beneficiary decannulating himself and requiring immediate skilled intervention to maintain his airway and provide immediate healthcare CPR as needed, as well as the other skilled needs that are in his current and described in the Nursing Addendum dated 7/6/16. MEunnv musulssm ME :aa-ao-zavs 17:3! FAX NDJ WE FILE NO - 335 DATE 05,30 16:10 Tu ,1 wssamzzse DOCUMENT PAGES '30 Sum TIME 08.3 END TNE 08.3 PAGES SENT . '30 STATUS UK "'succEssFUL TX 2190 .4 [Ana-m. 15:4 . Phonl' Dizzaoq'nv F-x 972-25041" 6 x- 2 r-meW Amman: CuInmny: No. orP-n- cm): 3 3 by: Conlrnanb: Ev-lu-le mg "mg POC I: 1 other; Ling--Mm mum". n. uan .m an, "raw mm bun-ulna Inn-fin 'numun-Id mblun < $233935! mammals: zloo Scum )5 flute 'zoc Anal-m, lx 757m Reqqu for Clinical for Appeal Dale: Augusl 23, 2016 Tu: Ruchelle Sutnn. RN with Cm Home Hedlh Inc Fax fl: sauna-m Man he! DASHON MORRIS x: Member 1m: Dlte ol mull: osnmzols Service Raqunltd: Privxle Duty Nuning (PDN) 16E hm." per week .l min qullefled We received me clinlcal summed with the .ppul. ll you have any other infolmation you would like to have consideved, please submit it ADDITIONAL INFORMATION MUST BE RECEIVED BY W16 Sell a Response lo: Letty Appe-Is szmmenl Fax i. 8609184266 23' Superior Heahhplan Attn: Appeals Coordinator RE: DASHON MORRIS a: 005- 05/02/2015 Dashan IS a currently a 15 month old male who has a tracheostomy as his primary means otventilation, His activity is progressing as he ages and moves all 4 extremities and has a habit oi pulling on his trach and it's accessories. He frequently decannulates himself and requires immediate skilled nursing intervention to get his trach re-cannulated and CPR to get him back to his baseline. This is not an occasional activity, this is primarily daily and more than one time a day. nashon's tracheostomy is within itself, an immlnent risk to his health status due to his medical fragility and risk of death, if skilled intervention is not available quick enough to oxygenate him, yet he i 's dependent on the tracheostomy tar hisventllatiantu be able to breath. Dashon's need iertracheostomy suctioning ls ongoing around the-clock at intervals in which frequency varies, but Dashon has been requiring tracheal suctioning at least hourly. Dashon also requires Oxygen to assist with his tracheostomy dependence for adequate ventilation. Dashon is also currently having issues with his stoma site that is going to require surgery. This very well could be a result oftrauma from frequent decannulation. Foster mom has not provided any of those documents related to the stoma issue. Pt was scheduled for stoma surgery on August 24, 1015, and it is being rescheduled due to the {act that while pt was in the care of the hospital for pre-dp that he tell out of the hospital bed. Pt requires continuous monitoring for his safety. Dashon was in the hospital in May for seizures and hypoglycemia. Since then and currently, he has had changes in his feedings and is also GB dependent ior his primary source of nutrition. He has had changes in medications for his GERD as well. Dashon has NOT been medically stable for a period of months now, yet Superior continues to decrease his nursing hours and care by placing him on a 2:1 ratio. The 2:1 ratio is cieariy contraindicated as it has contributed to unnecessary risks to patients health by lrequent CPR due to his decannulation, and is not in alignment with Texas Medicaid Providers Procedure Manual: Vol 2, Section 2.11.2. The clients' needs and PDC overlap with the other members needs and Pot. The other member that they are proposing the 1:1 with has also been approved for an authorilatlon cuss hours, 1: Ratio due to her lragile medical needs. Dashon also falls under the Texas Healthy Steps that his private duty nursing falls under 42 C.F.R 440.30, Private Duty Nursing is being requested for 153 hours 1:1 Ratio to ameliorate Dashon's disability and/or conditions as provided under42 u.s.c tasadlrilsi and with regards to 42 U.s.c. 1395a(a)(10)lB), 1396aialti, 1396d(r)(5), 41 CER. 440.230lc). During a phone conference with Dr. Biendle on August and 2016, he stated that he had not even reviewed the other member's informatiurl that they are wanting to include with the 2:1 Ratio. 0 it 213 divs/figure Mun some 2100 972.230.47'7 Camp-fly: . Nu. at My. (mcma-- nova): by: any." sum" mum fivm I I ASAP [1 .nk Car-e. Pr-o HOME HEALTH. INC. "mum Rs: u. an, mm. 75 145. 111-230-1746 MM swim storm-so: .33le mgSme 5999LB: fit so as: smus was 3M1 (mi awu mus 539w (Ii 31m 31H Luodan NOISS Amman superior LINDA BADAWO 1 June 2016 3340 SILVER CREEK DR MESQUITE, TX 75 81 Re: Reques! receivcd on: 05/25/2016 File No.: 0170650955567 Member/Patient name: DASHON moms Member/Patient No Mcmberll'aliem DOB: 05/02/2015 Requester: Cook Home Health chuesled Stan Dale: 05/24/2016 Service Requested: lnnapulmormry Percussive Ventilation (E1399) pedir que s: I: smile can can: en Espanol, por favor 111ml: STAR 1--800-783-5386. STAR MRSA 877--644-449', 1-866-516-4501, STAR Health 14663126283. Dear DASHON MORRIS: A special license far Utilization Review Agents (URA) is issued through the Texas Departmem nf Insurance and necessm'y to perronn medical reviews. Centene Cmnpany ofTexls, LP is licensed URA. and has completed the review on Ihis request. We received your request ror tile above services. Response to Request: Denied Inlnpulmumry Percussive Venlihdon (E1399) Effective Dale of Denial: 05/24/2016 10 10/17/2016 lire requested service is not medicniiy beoeuse lack ot medical necessity. Inlmpulmonary percussive venlilalors (pnwmatic positive pressure device used to move mucus) are considered experimental (trial) and investigationnl (study) for all indications (explanalions) because there is insumcient (not enough) evidence supponing quivnient (equnl) to or superior (supreme) to existing available mucus (a slippery secretion produced by, covering mucous membianes) clearing dcvices. We used Superior Healtiiplnn Policy ammo Experimental Policy to help us make tnis decision You may want to talk about decision with your doctor. Make sun: tiiat all ofthe information needed were given In superior. Your doctor can discuss this decision with our Mcdicai Director by calling Superior at 1-877-398- 946i. This decision was made by Superior Healthlan Medical Director Charlzs DuBose MD. He is board Cert! led in Pediatrics. 5:5 sure?cr . You have the right to: - File an appeal. - File a fair hearing. - File a complaint. - Get a free copy of the criteria used to make the decision. - Ask for a free copy of your case ?le. Your file might include medical records and any other information. 0 Send written comments or information that is important to your case. - Get someone to act in your place. That person could be a member of your family, a friend, a lawyer or a doctor. You must authorize this person to act in your place. - Get legal services. You may qualify for free or low cost legal services available in your area. A list of legal aid providers that may be able to help you is included with this letter. Look at the page with the title, ?Free Legal Services.? Continuing Services: To continue services the Appeal must involve the termination, suspension, or reduction of a previously authorized course of treatment and have been ordered by an authorized provider. 0 You must submit a request for an appeal on or before the later of 10 days from the date of the original denial letter, OR the day your service will be reduced or end. - The time period covered by the original authorization must not have ended. If the above are met the services will continue until any of the following happen: 0 You cancel the appeal. - Your appeal is denied. - The time period covered by the original authorization has ended. How to ?le an appeal: Contact Superior within 30 days, or based on your provider?s contract, from the date of the original denial letter. You can call us to ?le your appeal but we must also receive your appeal request in writing. Call us at 1-877-398- 9461 to ?le an appeal. You can fax or mail your request to us. Use the address and fax number at the bottom of this letter. A Member Advocate can help you. Call 1-800-783-5386 and ask for the Member Advocate. Appeal timeframe: Superior will mail you a letter 5 days after we get your appeal request so that you will know we got it. We will look into your appeal and send you an answer in writing. The appeal decision will be made by a doctor who has not reviewed the case before and who is not supervised by a doctor who reviewed the case before. Your appeal will be completed within 30 days after we receive your appeal request. The 30 days can be increased by 14 more days. You or someone acting for you can ask for this extension. We can also ask for an extension. A letter would be sent to you if we need an extension. In order for us to extend the time frame you have to tell us you agree. The letter will tell you why we need more time to make a decision. Fast appeals: You have the right to request a fast appeal. You can request a fast appeal if you or your Provider thinks that waiting for a standard appeal could put your life or health in danger. Call us at 1-877-398-9461 to request a fast appeal. Superior may or may not agree with your request for a fast appeal. If we agree, a fast appeal about an ongoing emergency or continued hospital stay will be ?nished no later than 1 business day after Superior receives the request. All fast appeals will be finished no later than 3 days from the date you asked for the appeal. If we do not agree with your request for a fast appeal, we will let you know. Your request would then go through the regular appeal process and you would get an answer in 30 days. How to ?le a fair hearing: If you disagree with our decision, you can request a fair hearing. You may name someone to represent you. A doctor or other medical Provider may be your representative. You can request this by calling us or writing a letter to us with the name of the person you want to represent you. If you want to ask for a fair hearing, you can contact us by calling the Appeals Coordinator at 1-877-398-9461. You can fax or mail your request to us. Use the address and fax number at the bottom of this letter. A hearing officer will listen to the appeal and see that you are treated fairly. You may be at the fair hearing or you may ask someone to represent you at the hearing with the information you have provided. If you ask for a fair hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. You have 90 days to request a fair hearing from the date of the original denial letter or you may lose the right to a fair hearing. The Texas Health and Human Services Commission will make a ?nal decision within 90 days from the date the fair hearing is asked for. How to ?le a complaint: You can call Superior toll-free at 1-800-783-53 86 to tell us about your problem. You can also ?le a complaint through our website. Go to Click on "Contact Us" in the top right corner of the page. You can also use Superior's complaint form. A copy of the complaint form can be printed from Superior's website. You can mail the form to: Centene Company of Texas ATTN: Complaints 2100 South 11-1-35, Suite 200 Austin, TX 78704 You can also fax your form to 1-866-683-5369. Complaint time frame: We will send you a letter 5 days after we get your complaint to let you know we got it. Superior will have an answer to your complaint within 30 days of the date you submit your complaint. Other Options: You may not agree with our answer. You can ask us to change it. That is called a complaint appeal. You have 90 days from the date on our answer letter to ask for a complaint appeal. If you ask for a complaint appeal, we will hold a meeting at a time and place that is good for you. We will discuss your complaint appeal. You can come to the meeting. You could write a letter instead. We will go over your letter at the meeting and then send you an answer. We will mail it within 60 days of getting your complaint appeal. If you are not satis?ed with Superior?s answer to your complaint, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free to 1-866-566-8989. If you would like to make your request in writing, send it to: Texas Health and Human Services Commission Health Plan Operations H320 ATTN: Resolution Services PO. Box 85200 Austin, TX 78708?5200 Also, you can send your complaint in an email to Additional help: Superior can help you with case management. Case management can help you get the services you need and even tell you about other help available to you. You can call Superior at 1- 800?783- 53 86 and ask for information about programs that can help you. Centene Company of Texas Attn: Appeal Coordinator 2100 S. Ill-35, Suite 200 Austin, TX 78704 1-877-398-9461 Fax: 1-866-918-2266 TTY: 1-800-735-2989 We will not be unfair to you if you ?le an appeal, fair hearing or complaint. Sincerely, Medical Director Centene Company of Texas cc: Cook Childrens Home Health Dr. Pravin Sah Legal Services for Low-income Texans Texas Rio Grande Legal Aid 1-888-988-9996 Texas Rio Grande Legal Aid serves the following counties/ Texas Rio Grande Legal Aid presta servicios en los siguientes condados: Aransas, Atascosa, Bandera, Bastrop, Bee, Bexar, Blanco, Brewster, Brooks, Burner, Caldwell, Calhoun, Cameron, Coma], Crockett, Culberson, DeWitt, Dimmit, Duval, Edwards, El Paso, Frio, Gillespie, Goliad, Gonzales, Guadalupe, Hays, Hidalgo, Hudspeth,]ackson, jeff Davis, Jim Hogg, Jim Wells, Karnes, Kendall, Kennedy, Kerr, Kimble, Kinney, Kleberg, La Salle, Lavaca, Live Oak, Llano, Mason, Maverick, McMullen, Medina, Nueces, Pecos, Presidio, Real, Reeves, Refugio, San Patricio, Starr, Sutton, Terrell, Travis, Uvalde, Val Verde, Victoria, Webb, Willacy, Williamson, Wilson, Zapata and Zavala. Lone Star Legal Aid 1-800-733-8394 Lone Star Legal Aid serves the following counties/ Lone Star Legal Aid presta servicios en los siguientes condados: Anderson, Angelina, Austin, Bell, Bosque, Bowie, Brazoria, Brazos, Burleson, Camp, Cass, Chambers, Cherokee, Colorado, Coryell, Delta, Falls, Fayette, Fort Bend, Franklin, Freestone, Galveston, Gregg, Grimes, Hamilton, Hardin, Harris, Harrison, Henderson, Hill, Hopkins, Houston, Jasper, Jefferson, Lamar, Lampasas, Lee, Leon, Liberty, Limestone, Madison, Marion, Matagorda, McLennan, Milam, Montgomery, Morris, acogdoches, Navarro, Newton, Orange, Panola, Polk, Rains, Red River, Robertson, Rusk, Sabine, San Augustine, San Jacinto, Shelby, Smith, Titus, Trinity, Tyler, Upshur, Van Zandt, Walker, Waller, Washington, Wharton and Wood. Legal Aid of North West Texas wwaanwt.org Legal Aid of North West Texas serves the following areas/ Legal Aid of North West Texas presta servicios en los sigientes condados: Abilene 800-933-8591 Midland 800-926-5630 Amarillo BUG-0556808 Odessa 800-955?1307 Brownwood 325-646-8659 Plainview 800-955? 8491 Dallas 214-?48-1234 San Angelo 800-284-5180 Denton 800-955-140? Waxahachie 86061431344 Fort Worth 80f 1394-9734 Weatherford 800?9616708 Lubbock 800333-455? Wichita Falls 800-926-5542 McKinney 800-906-3045 Midland 800-926-5630 The Regency Building 2100 South 11-1-35, Suite 200 Austin, TX 78704 superior 2100 Snulh iH Suite 200 Austin TX 72704 28 Oclnbar 2016 LINDA BADAWO 3340 SILVER CREEK DR MESQUITE, TX 75181 Re/Asuma: Fiivme Duly Nuising (PDN) 165 haul! a week (1 10 1 Elia) Request received on/ Solicitud iecibida el, 10/25/2016 File NOJ Expedienle 0P0565150775 Mamba/Fallen! name/Nombre de afiliado/pamema. DASHON MORRIS Member/Fallen! Ge <28 October 2016 Estimado/a DASHON MORRIS, Hemos recibido su solicitud para los servicios antes mencionados. Respuesta a la solicitud: Denegado Servicios de enfermeria privados168 horas (1 a 1 proporci?n Aprobado: Servicios de enfermeria privados168 horas (1 a 1 proporci?n desde 10/25/2016 a 12/06/2016 Fecha efectiva de la denegacion: 01/25/2016 to 01/22/201 7 El servicio soiicitado no es m?dicamente necesario porque la informacion recibida soto admite una aprobaci?n parcial del servicio solicitado Hemos utilizado polizas, guias, criterios y/o la valoraci?n experiencia de nuestro m?dico para ayudarnos a tomar esta decisi?n. La informacic?m m?dica recibida puede apoyar la autorizaci?n de servicios m?dicos de enfermeria especializada prestados en el hogar. Los servicios m?dicos de enfermeria especializada prestados en el hogar son servicios de enfermerl?a prestados en base a visitas. Los servicios m?dicos de enfermeria especializada prestados en ei hogar pueden satisfacer necesidades de atenci?n m?dica agudas, prestarse de manera continua para atender afecciones cronicas. Para obtener mas informaci?n averiguar cc'>mo obtener servicios medicos de enfermeria especializada prestados en el hogar, debe comunicarse con Servicios para A?liados de Superior llamando al 1-866-912-6283 0 con su proveedor m?dico. Quizas le interese hablar sobre esta decision con su m?dico. Asegurese de que toda la inforrnacion necesaria haya sido entregada a Superior. Su medico puede discutir esta decisi?n con nuestro Director M?dico llamando a Superior at 1-877-398-9461. Esta decision fue tomada por ei Director M?dico de Superior quien esta acreditado por el consejo m?dico. You have the right to: File an appeal. File a fair hearing. File a complaint. Get a free copy of the criteria used to make the decision. Ask for a free copy of your case file. Your ?le might include medical records and any other information. Send written comments or information that is important to your case. Get someone to act in your place. That person could be a member of your family. a friend. a lawyer or a doctor. You must authorize this person to act in your place. . Get legal services. You may qualify for free or low cost legal services available in your area. list of legal aid providers that may be able to help you is included with this letter. Look at the page with the title, ?Free Legal Services". Continuing Services: To continue services: - You must request an appeal or a fair hearing within 10 days from the date of the original denial letter. or the day your service will be reduced or end. You must say in your request that you want to continue services. The denied services must have been previously authorized. The time period covered by the original authorization must not have ended. If the above are met the services will continue until any of the following happen: a You cancel the appeal or fair hearing. 0 Your appeal or fair hearing is denied. 0 The time period covered by the original authorization has ended. How to ?le an appeal: Contact Superior within 30 days from the date of the original denial letter. You can call us to ?le your appeal but we must also receive your appeal request in writing. Call us at 1-877-398-9461 to ?le an appeal. You can fax or mail your request to us. Use the address and fax number at the bottom of this letter. A Member Advocate can help you. Call 1-800-783-5386 and ask for the Member Advocate. Appeal timeframe: Superior will mail you a letter 5 days after we get your appeal request so that you will know we got it. We will look into your appeal and send you an answer in writing. The appeal decision will be made by a doctor who has not reviewed the case before and who is not supervised by a doctor who reviewed the case before. Your appeal will be completed within 30 days after we receive your appeal request. The 30 days can be increased by 14 more days. You or someone acting for you can ask for this extension. We can also ask for an extension. A letter would be sent to you if we need an extension. In order for us to extend the time frame you have to tell us you agree. The letter will tell you why we need more time to make a decision. Fast appeals: You have the right to request a fast appeal. You can request a fast appeal if you or your Provider thinks that waiting for a standard appeal could put your life or health in danger. Call us at 1?877-398-9461 to request a fast appeal. Superior may or may not agree with your request for a fast appeal. If we agree. a fast appeal about an ongoing emergency or continued hospital stay will be ?nished no later than 1 business day after Superior receives the request. All fast appeals will be ?nished no later than 3 days from the date you asked for the appeal. If we do not agree with your request for a fast appeal, we will let you know. Your request would then go through the regular appeal process and you would get an answer in 30 days. Usted tiene el derecho a: . Presentar una apelacic?m. Solicitar una audiencia imparcial. Presenter una queja. Obtener una copia gratuita de los criterios que fueron utilizados para tomar la decisi?n. Solicitar una copia gratuita de su expediente. Su expediente puede incluir registros m?dicos otro tipo de informaci?n. Enviar comentarios informacion por escrito que sean importante para su caso. Coordinar para que alguien Ie represente. Esa persona podria ser un miembro de su familia. un amigo. un abogado 0 un m?dico. Debe auton'zar a esta persona a actuar en su lugar. - Obtener servicios legales. Puede calificar para obtener servicios legales gratuitos 0 de bajo costos disponibles en su area. Con esta carta se incluye una lista de proveedores de asistencia legal que podrian ayudarlo. Consulte la pagina con el titulo ?Servicios legales gratuitos". Continuacion de servicios: Para lograr la continuidad de Ios servicios: Debe solicitar una apelaci?n una audiencia imparcial dentro de los 10 dias de la fecha de la carta original de denegaci?n. 0 el dia en que sus servicios seran reducidos terminados. Debe indicar en su solicitud que desea continuar Ios servicios. . Los servicios denegados deben haber sido autorizados previamente. No debe haber ?nalizado el periodo de tiempo cubierto por la autorizaci?n original. Si se cumplen los requisitos anteriores, los servicios continuaran hasta que ocurra cualquiera de las siguientes situaciones: Usted cancela la apelaci?n la audiencia imparcial. - Su apelaci?n audiencia imparcial es denegada. - Finaliza el periodo de tiempo cubierto por la autorizacion original. COmo presentar una apelaci?n: Comuniquese con Superior dentro de los 30 dias de la fecha de la carta de denegacion original. Puede llamamos para presentar su apelacion, pero tambi?n debera enviarnos su solicitud de apelaci?n por escrito. Para presentar una apelaci?n llamenos al 1-877-398-9461. Puede remitimos su solicitud por fax 0 par correo. Utilice la direcoi?n el mimero de fax que ?guran en la parte inferior de esta carta. Un defensor de afiliados puede ayudarlo. Llame al 1-800-783-5386 pregunte por el defensor de a?liados. Plazo para la revisi?n de la apelaci?n: Superior le enviara una carta por correo 5 dias despu?s de recibir su solicitud de apelaci?n para informarle que la recibimos. Analizaremos su apelaoic?an Ie enviaremos una respuesta por escrito. La decisi?n respecto a la apelacion sera tomada por un m?dico que no haya revisado el caso antes que no sea supervisado por un m?dico que si reviso el caso antes. Su apelaci?n se completara en un plazo 3O dias despu?s de que recibamos su solicitud de apelaoi?n. Los 30 dias puede incrementarse en 14 dias mas. Usted alguien actuando en su nombre puede pedir esta extensi?n. Nosotros tambi?n podemos pedir una extensibn. Se le enviaria una carta en caso de necesitar una extension. Para que podamos extender el plazo de tiempo, usted nos debe indicar que esta de acuerdo. La carta le indicara por qu? necesitamos mas tiempo para tomar una decisi?n. Apelaciones r?pidas: Tiene el derecho a solicitar una apelacion rapida. Puede solicitar una apelaci?n rapida si usted su proveedor consideran que esperar el plazo de una apelaci?n estandar podrl'a poner su Vida su salud en peligro. Llamenos al 1-877-398-9461 para solicitar una apelacion rapida. Superior podria no estar de acuerdo con su solicitud para una apelaci?n rapida. En el caso de estar de acuerdo. una apelacion rapida respecto a una emergencia en curso una intemaci?n continuada se completara en no mas de 1 dia habil despu?s de que Superior reciba la solicitud. Todas las apelaciones rapidas se completaran en no mas de 3 dias a partir de la fecha en que se solicite la apelacion. Si no estamos de acuerdo con su solicitud para una apelaci?n rapida. le informaremos aI respecto. En tal caso, su petici?n se tramitara mediante e! proceso de apelacion est?ndar recibira una respuesta en 30 dias. How to ?le a fair hearing: If you disagree with our decision, you can request a fair hearing. You may name someone to represent you. A doctor or other medical Provider may be your representative. You can request this by calling us or writing a letter to us with the name of the person you want to represent you. If you want to ask for a fair hearing. you can contact us by calling the Appeals Coordinator at 1-877-398-9461. You can fax or mail your request to us. Use the address and fax number at the bottom of this letter. A hearing of?cer will listen to the appeal and see that you are treated fairly. You may be at the fair hearing or you may ask someone to represent you at the hearing with the information you have provided. If you ask for a fair hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. You have 90 days to request a fair hearing from the date of the original denial letter or you may lose the right to a fair hearing. The Texas Health and Human Services Commission will make a final decision within 90 days from the date the fair hearing is asked for. How to ?le a complaint: You can call Superior toil-free at 1-800-783-5386 to teli us about your problem. You can also file a complaint through our website. Go to Click on "Contact Us" in the top right corner of the page. You can also use Superior?s complaint form. A copy of the complaint form can be printed from Superior's website. You can mail the form to: Centene Company of Texas, ATTN: Complaints. 2100 South lit-35, Suite 200 Austin, TX 78704. You can also fax your form to 1-868-683-5369. Complaint time frame: We will send you a letter 5 days after we get your complaint to let you know we got it. Superior will have an answer to your complaint within 30 days of the date you submit your comptaint. Other Options: You may not agree with our answer. You can ask us to change it. That is called a complaint appeal. You have 90 days from the date on our answer fetter to ask for a complaint appeal. If you ask for a complaint appeal, we will hold a meeting at a time and place that is good for you. We will discuss your complaint appeal. You can come to the meeting. You could write a letter instead. We will go over your letter at the meeting and then send you an answer. We will mail it within 60 days of getting your complaint appeal. if you are not satisfied with Superior?s answer to your complaint. you can complain to the Health and Human Services Commission (HHSC) by calling toil-free to 1-866?566-8989. If you would like to make your request in writing, send it to: Texas Health and Human Services Commission, Health Plan Operations H320, ATTN: Resolution Services, PO. Box 85200, Austin, TX 78708-5200. Also, you can send your complaint in an email to come solicitar una audiencia imparcial: Si no esta de aouerdo con nuestra decision, puede solicitar una audiencia imparcial. Puede nombrar a alguien para que lo represents. Su representante puede ser un m?dico otro proveedor m?dico. Para solicitar Io anterior Ilamenos envienos una oarta con el nombre de la persona que desea que lo represente. Si desea solicitar una audiencia imparcial, puede contactarnos llamando al Coordinador de Apelaciones al 1-877-398-9461. Puede remitirnos su solicitud por fax 0 por correo. Utilioe la direcci?n el nL?imero de fax que ?guran en la parte inferior de esta carta. Un funcionario de audiencias escuchara la apelacion garantizara que reciba un trato justo. Usted puede presenciar Ia audiencia imparcial puede pedirle a alguien que lo represents en la audiencia con la informaci?n que haya proporcionado. Si solicita una audiencia imparcial, recibira un paquete de informaci?n que Ie indicara la fecha, la hora el lugar de la audiencia. La mayoria de Ias audiencias imparciaies se llevan a cabo por tel?fono. Durante Ia audiencia, usted su representante podr?n explicar por qu? necesita el servicio que el plan de salud rechazo. - Tiene 90 dias para solicitar una audiencia imparcial a partir de la fecha de la carta original de denegaci?n; luego de dicho plazo puede perder ei derecho a una audiencia imparcial. La Comisi?n de Servicios Humanos de la Salud de Texas tomara una decision ?nal dentro de los 90 dias de la fecha en que se solicite la audiencia imparcial. C?mo presentar una queja: Puede llamar 3 Superior sin costo al 1-800-783-5386 para hacernos saber acerca de su problema. Tambi?n puede presentar una queja a trav?s de nuestro sitio web. Visite Haga ciic en "Contactenos" en la esquina superior derecha de la pagina. Tambi?n puede user at formulario de quejas de Superior. Puede imprimir una copia del fonnuiario de quejas disponible en el sitio web de Superior. Puede enviar el formulario por oorreo a: Centene Company of Texas, ATTN: Compiaints/Quejas, 2100 South lH-35, Suite 200 Austin, TX 78704. Tambi?n puede enviar el formuiario por fax at 1-866-683-5369. Plazos para la revisi?n de la queja: Le enviaremos una carta 5 dias despu?s de haber recibido su queja para hacerle saber que la recibimos. Superior respondera su queja dentro de los 30 dias siguientes a la fecha en que presento su queja. Otras opciones: Usted podria no estar de acuerdo con nuestra respuesta. Puede solicitarnos que la modi?quemos. Eso se denomina apelacion de queja. Tiene 90 dias desde la fecha de nuestra carta de respuesta para solicitar una apelacion de queja. Si solicita una apelacion de queja, llevaremos a cabo una reuni?n en el dia, horario lugar que le sean convenientes. Debatiremos sobre su apelacion de queja. Usted puede venir a la reunic?m. 0, en lugar de ello puede enviarnos una carta. Analizaremos su oarta en la reuni?n luego le enviaremos una respuesta. Se la enviaremos por correo dentro de los 60 dias de recibir su apelaci?n de queja. Si no esta? satisfecho con la respuesta de Superior a su queja. puede presenter una queja a la Comisi?n de Servicios Humanos de la Salud de Texas (HHSC) llamando a la Iinea gratuita 1?866-566?8989. Si desea presenter su soiicitud por escrito, enviela a: La Comisic?m de Servicios Humanos de la Salud de Texas, Health Plan Operations H320, Resolution Services. PO. Box 85200. Austin, TX 78708-5200. Tambi?n puede enviar su queja por correo electronico a Additional help: Superior can help you with case management. Case management can help you get the services you need and even tell you about other help available to you. You can call Superior at 1-800-783-5386 and ask for information about programs that can help you. If you need help understanding this letter or if you want to learn more, you or your representative can call or write Superior at: Centene Company of Texas, Attn: Appeal Coordinator. 2100 S. lH-35. Suite 200.Austin, TX 78704. 1677-3918-9461, Fax: 1-800-735-2989. We will not be unfairto you if you ?le an appeal. fair hearing or complaint. Sincerely, Superior Medical Management cc: Care Pro Home Health Inc Dr. Heidi Kloster Roman Ayuda adicional: Superior puede ayudario con la administraci?n de casos. La administraci?n de casos puede ayudario a recibir los servicios que necesita incluso informarle sobre otro tipo de ayuda disponibie. Puede llamar a Superior al 1- 800-783-5386 solicitar informacion sobre los programas que pueden ayudarlo. Si necesita ayuda para entender esta carta si quiere saber mas al respecto. usted su representante pueden ilamar escribir a Superior HealthPIan a: Centene Company of Texas, Appeal Coordinator, 2100 S. Suite 200, Austin, TX 78704. 1-877-398-9461. Fax: 1-866-918-2266, TTY: 1-800-735-2989. No to trataremos injustamente por haber solicitado una apeiaci?n. una audiencia imparcial presentar una queja. Atentamente. Superior HealthPIan Medical Management superior 2 titan 3n 22 July 2016 DASHON MORRIS 3341} SILVER CREEK DR MESQUITE, TX 751 Bl Rs/Asuma: anete Duty Nursing (PDN) 168 hours per week Request received on/ Sollcnud recioida at, 07/15/2015 File No/ Expadiente 0P0566150775 Member/Patient name/Nombre da antiedo/paciente: DASHON MORRIS Member/Patient DOB/Fscha de necrniento: 05/02/2015 Member/Patient lD no/tir dis identMeacion del Miemoro: Reguester/Solrcitante: Care Pro Home Health in: Requested Start Data/Pesha de inicio soliciteda: 07/17/2016 Dear DASHON MORRIS: We received your request torthe above services Request Denl'd Private Duty (PDN) 168 hours per week at 1:1 ratlo Approvid Prlvame Duly Nursan (PDN) I12 hours wuk at 1:1 mlo from to 10/1412016 Eflacflva Dam OI Donialt 07I25l2016 lo 1W14l2016 The requested service is not medically necessary because Private Duty Nursing (PDN) hours oi 112 is medically necessary with 2 to paring. Any additional Private Duty Nursing hours is not medically necessary, Dasnon is on continuous (constant) supplemental (additional) oxygen without titration (allow you to detennina the precise endpoints/a reaction) per horne nursing notes He receives G-tuoa (a surgical procedure /or inserting atuoe through the ahdoman wall and into the stomach) reeds four times per day over one hour and continuous reeds ror six hours during the night. He requires tracheal suctioning tracheal auctioning (removes thick mucus and secretions from the trachea and lower airway that you are not ahle to clear by coughing) or secretions. However. tracheal suctioning or 75 times per hour is inappropriate (no! correct) as this will cause trauma and damage to the trachea (the windpipe), He does not require ventilatory (mechanical hreathing) suppon. Administration (giving) of oral (mouth) or g-luhe medications. monitoring the pulse oximetry (measuring the concentration at oxygen in the olood), moni1onng tor seizures (changes in the brain's electrical activity) inhaler (handheld portable devices that deliver medication to your lungs) or nehutixer treatments (hreathing treatments), oral or (superfian auctioning) auctioning and age approonete hygiene do not met criteria /or Private Duty Nursing as they are not continuous skilled nursing needs. There is no indicatton (explanation) that he needs to be changed from 1:2 ratio irom the documentation (inronnation) submitted as monitoring o/ oehavior including removing/pulling out trash in not a continuous skilled nursing need It does not meet criteria tor anata Duty Nursing sources We used May 2016 Texas Medicaid Provider Procedures Manual: Vol 2; Children's Services Handbook; Section 2.13 and PDN Review and Memoer to Nurse Ratio oetermrnation Process Faun/.1720 to help us make this decision The medical information received may suppon authorization oi home nee/1h skilled nursing services Home hea/th skilled nursing services are nursing services provided on a per-visit oasis Home health skilled nursing services may be provided to meet acute care needs, or on an ongoing basis to meet chronic needs. For more iniormation and to find out how to ootain home health skilled nursing services you should contact Superior Member Sen/ices at 1-8668126283 or your Provider, ii 30," men on t'F is licensed WA am} this i Ammo/rm q/i the roves eiilunu norm; SuperiovHea thPlan.com You may want to talk about this decision with your doctor. Make sure that all of the information needed to support the request was given to Superior. Your doctor can discuss this decision with our Medical Director by calling 1- 877-398-9461. This decision was made by Superior Medical Director, Charles DuBose MD. He is board certi?ed in Pediatrics. 22 July 2016 Estimadola DASHON MORRIS, Hemos recibido su solicitud para Ios servicios antes mencionados. Respuesta a la solicitud: Denegado Servicios de enfemeria privados 168 horas por semana Aprobado Servicios de enfenneria privados 112 horas por semana Fecha efectiva de la denegacion: 071252016 a 10/14/2016 El servicio solicitado no es m?dicamente necesario porque Ia informaci?n recibida no cumplio con Ios criterios requeridos Hemos utilizado polizas. guias. criterios ylo Ia valoracion experiencia de nuestro m?dico para ayudarnos a tomar esta decision. La informaci?n m?dica recibida puede apoyar Ia autorizaci?n de servicios m?dicos de enfermeria especializada prestados en el hogar. Los servicios m?dicos de enfermeria especializada prestados en ei hogar son servicios de enfermeria prestados en base a visitas. Los servicios m?dicos de enfermerl?a especiaiizada prestados en el hogar pueden satisfacer necesidades de atencion m?dica agudas, prestarse de manera continua para atender afecciones cronicas. Para obtener mas informacion averiguar c?mo obtener servicios m?dicos de enfermeria especializada prestados en el hogar, debe comunicarse con Servicios para A?liados de Superior llamando al 1-866-912-6283 0 con su proveedor m?dico. Quizas Ie interese hablar sobre esta decisi?n con su m?dico. Asegurese de que toda la infonnacion necesaria haya sido entregada a Superior. Su m?dico puede discutir esta decisi?n con nuestro Director M?dico llamando a Superior al 1-877-398-9461. Esta decisic?m fue tomada por el Director M?dico de Superior quien esta acreditado por ei consejo m?dico. You have the right to: File an appeal. File a fair hearing. File a complaint. Get a free copy of the criteria used to make the decision. Ask for a free copy of your case ?le. Your ?le might include medical records and any other information. Send written comments or information that is important to your case. Get someone to act in your place. That person could be a member of your family, a friend, a lawyer or a doctor. You must authorize this person to act in your place. 0 Get legal services. You may qualify for free or low cost legal services available in your area. A list of legal aid providers that may be able to help you is included with this letter. Look at the page with the title. ?Free Legal Services". Continuing Services: To continue services: . You must request an appeal or a fair hearing within 10 days from the date of the original denial letter. or the day your service will be reduced or end. . You must say in your request that you want to continue services. The denied services must have been previously authorized. The time period covered by the original authorization must not have ended. If the above are met the services will continue until any of the following happen: . You cancel the appeal or fair hearing. - Your appeal or fair hearing is denied. . The time period covered by the original authorization has ended. How to file an appeal: Contact Superior within 30 days from the date of the original denial letter. You can call us to file your appeal but we must also receive your appeal request in writing. Call us at 1-877-398-9461 to ?le an appeal. You can fax or mail your request to us. Use the address and fax number at the bottom of this letter. A Member Advocate can help you. Call 1-800-783-5386 and ask for the Member Advocate. Appeal timeframe: Superior will mail you a letter 5 days after we get your appeal request so that you will know we got it. We will look into your appeal and send you an answer in writing. The appeal decision will be made by a doctor who has not reviewed the case before and who is not supervised by a doctor who reviewed the case before. Your appeal will be completed within 30 days after we receive your appeal request. The 30 days can be increased by 14 more days. You or someone acting for you can ask for this extension. We can also ask for an extension. A letter would be sent to you if we need an extension. In order for us to extend the time frame you have to tell us you agree. The letter will tell you why we need more time to make a decision. Fast appeals: You have the right to request a fast appeal. You can request a fast appeal if you or your Provider thinks that waiting for a standard appeal could put your life or health in danger. Call us at 1-877-398-9461 to request a fast appeal. Superior may or may not agree with your request for a fast appeal. If we agree. a fast appeal about an ongoing emergency or continued hospital stay will be ?nished no later than 1 business day after Superior receives the request. All fast appeals will be finished no tater than 3 days from the date you asked for the appeal. If we do not agree with your request for a fast appeal, we will let you know. Your request would then go through the regular appeal process and you would get an answer in 30 days. Usted tiene el derecho a: . Presentar una apelacion. Solicitar una audiencia imparcial. Presentar una queja. Obtener una copia gratuita de los criterios que fueron utilizados para tomar la decision. Solicitar una copia gratuita de su expediente. Su expediente puede incluir registros m?dicos otro tipo de informacion. Enviar comentarios informacion por escrito que sean importante para su caso. Coordinar para que alguien le represente. Esa persona podria ser un miembro de su familia. un amigo, un abogado 0 un m?dico. Debe autorizar a esta persona a actuar en su lugar. . Obtener servicios legales. Puede cali?car para obtener servicios legales gratuitos 0 de bajo costos disponibles en su area. Con esta carta se incluye una lista de proveedores de asistencia legal que podrlan ayudarlo. Consulte la pagina con el titulo ?Servicios legales gratuitos". Continuacion de servicios: Para lograr la continuidad de los servicios: 0 Babe solicitar una apelacic?m una audiencia imparcial dentro de los 10 dias de la fecha de la carta original de denegacion, 0 el dia en que sus servicios seran reducidos tenninados. Debe indicar en su solicitud que desea continuar los servicios. Los servicios denegados deben haber sido autorizados previamente. No debe haber ?nalizado el periodo de tiempo cubierto por la autorizaci?n original. Si se cumplen los requisitos anteriores, los servicios continuaran hasta que ocurra cualquiera de las siguientes situaciones: . Usted cancela Ia apelacion la audiencia imparcial. - Su apelaci?n audiencia imparcial es denegada. . Finaliza el periodo de tiempo cubierto por la autorizacion original. C?mo presentar una apelacion: Comuniquese con Superior dentro de los 30 dies de la fecha de la carta de denegaci?n original. Puede llamarnos para presentar su apelaci?n. pero tambi?n debera enviarnos su solicitud de apelacic?m por escrito. Para presentar una apelaci?n ll?menos al 1-877-398-9461. Puede remitirnos su solicitud por fax 0 per correo. Utilice Ia direcci?n el mimero de fax que ?guran en la parte inferior de esta carta. Un defensor de a?liados puede ayudarlo. Llame al 1-800-783-5386 pregunte por el defensor de a?liados. Plazo para la revision de la apelaci?n: Superior Ie enviara una carta por correo 5 dias despues de recibir su solicitud de apelacion para informarle que la recibimos. Analizaremos su apelacic'm le enviaremos una respuesta por escrito. La decisi?n respecto a la apelacion sera tomada por un m?dico que no haya revisado el caso antes que no sea supervisado por un m?dico que si reviso el caso antes. Su apelacion se completara en un plazo 30 dies despu?s de que recibamos su solicitud de apelaci?n. Los 30 dies puede lncrementarse en 14 dies mas. Usted alguien actuando en su nombre puede pedir esta extensic'm. Nosotros tambi?n podemos pedir una extension. Se Ie enviaria una carta en caso de necesitar una extensibn. Para que podamos extender el plazo de tiempo, usted nos debe indicar que esta de acuerdo. La carta le indicara por que necesitamos mas tiempo para tomar una decision. Apelaciones rapidas: Tiene el derecho a soiicitar una apelacion rapida. Puede solicitar una apelaci?n rapida si usted su proveedor consideran que esperar el plazo de una apelacion estandar podria poner su Vida su salud en peligro. Llamenos al 1-877-398-9461 para solicitar una apelaci?n rapida. Superior podria no estar de acuerdo con su solicitud para una apelacion rapida. En el caso de estar de acuerdo. una apelaci?n rapida respecto a una emergencia en curso una internacion continuada se completara en no mas de 1 dia habil despu?s de que Superior reciba la solicitud. Todas las apelaciones rapidas se completaran en no mas de 3 dias a partir de la fecha en que se solicite la apelacion. Si no estamos de acuerdo con su solicitud para una apelaci?n rapida, le informaremos al respecto. En tal caso, su petioi?n se tramitara mediante el proceso de apelacion estandar recibira una respuesta en 30 dies. How to ?le a fair hearing: If you disagree with our decision, you can request a fair hearing. You may name someone to represent you. A doctor or other medical Provider may be your representative. You can request this by calling us or writing a ietter to us with the name of the person you want to represent you. If you want to ask for a fair hearing, you can contact us by calling the Appeals Coordinator at 1-877?398-9461. You can fax or mail your request to us. Use the address and fax number at the bottom of this letter. A hearing of?cer will listen to the appeal and see that you are treated fairly. You may be at the fair hearing or you may ask someone to represent you at the hearing with the information you have provided. If you ask for a fair hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. You have 90 days to request a fair hearing from the date of the original denial letter or you may lose the right to a fair hearing. The Texas Health and Human Services Commission will make a final decision within 90 days from the date the fair hearing is asked for. How to file a complaint: You can call Superior toli-free at 1600-7836386 to tell us about your problem. You can also file a complaint through our website. Go to Click on "Contact Us" in the top right corner of the page. You can also use Superior's complaint form. A copy of the complaint form can be printed from Superior's website. You can mail the form to: Centene Company of Texas, ATTN: Complaints, 2100 South lH-35, Suite 200 Austin, TX 78704. You can also fax yourform to 1?866-683-5369. Complaint time frame: We will send you a letter 5 days after we get your complaint to let you know we got it. Superior will have an answer to your complaint within 30 days of the date you submit your complaint. Other Options: You may not agree with our answer. You can ask us to change it. That is called a complaint appeal. You have 90 days from the date on our answer letter to ask for a complaint appeal. If you ask for a complaint appeal, we will hold a meeting at a time and place that is good for you. We will discuss your complaint appeal. You can come to the meeting. You could write a letter instead. We will go over your letter at the meeting and then send you an answer. We will mail it within 60 days of getting your complaint appeal. If you are not satisfied with Superior's answer to your complaint, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free to 1-866-566-8989. If you would like to make your request in writing, send it to: Texas Health and Human Services Commission, Health Plan Operations - H320, ATTN: Resolution Services. PO. Box 85200, Austin, TX 78703-5200. Also, you can send your complaint in an email to como solicitar una audiencia imparcial: Si no esta de acuerdo con nuestra decisic?m, puede solicitar una audiencia imparcial. Puede nombrar a alguien para que lo represente. Su representante puede ser un m?dioo otro proveedor m?dico. Para solicitar lo anterior llamenos envienos una carta con el nombre de la persona que desea que lo represente. Si desea solicitar una audiencia imparcial, puede contactarnos llamando al Coordinador de Apelaoiones al 1-877-398-9461. Puede remitirnos su solicitud por fax 0 por correo. Utilice la direcci?n el nLimero de fax que ?guran en la parte inferior de esta carta. Un funcionario de audiencias escuchara la apelacion garantizara que reciba un trato justo. Usted puede presenciar la audiencia imparcial puede pedirle a alguien que lo represente en la audiencia con la informaci?n que haya proporcionado. Si solicita una audiencia imparcial, recibira un paquete de infonnacion que le indicara la fecha, la hora el lugar de la audiencia. La mayoria de las audiencias imparciales se llevan a cabo por tel?fono. Durante la audiencia. usted su representante podran explicar por qu? necesita el servicio que el plan de salud rechazo. Tiene 90 dias para solicitar una audiencia imparcial a partir de la fecha de la carta original de denegaci?n; luego de dicho plazo puede perder el derecho a una audiencia imparcial. La Comision de Servicios Humanos de la Salud de Texas tornara una decisi?n ?nal dentro de los 90 dias de la fecha en que se solicite la audiencia imparcial. como presentar una queja: Puede llamar a Superior sin costo al 1-800-783-5386 para hacernos saber acerca de su problema. Tambi?n puede presentar una queja a trav?s de nuestro sitio web. Visite Haga clic en "Contactenos" en la esquina superior dereoha de la pagina. Tambi?n puede usar el formulario de quejas de Superior. Puede imprimir una copia del formuiario de quejas disponible en el sitio web de Superior. Puede enviar el formulario por correo a: Centene Company of Texas, ATTN: Complaints/Quejas. 2100 South lH-35, Suite 200 Austin, TX 78704. Tambi?n puede enviar el formuiario por fax al 1-866?683-5369. Plazos para la revision de la queja: Le enviaremos una carta 5 dias despu?s de haber recibido su queja para hacerle saber que la recibimos. Superior respondera su queja dentro de los 30 dias siguientes a la fecha en que presento su queja. Otras opciones: Usted podria no estar de acuerdo con nuestra respuesta. Puede solicitarnos que la modi?quemos. Eso se denomina apelacion de queja. Tiene 90 dias desde la fecha de nuestra carta de respuesta para solicitar una apelacion de queja. Si solicita una apelacion de queja, Ilevaremos a cabo una reuni?n en el dia, horario lugar que le sean convenientes. Debatiremos sobre su apelaci?n de queja. Usted puede venir a la reuni?n. 0, en lugar de ello puede enviarnos una carta. Analizaremos su carta en la reuni?n luego le enviaremos una respuesta. Se la enviaremos por correo dentro de los 60 dias de recibir su apelaci?n de queja. Si no esta satisfecho con la respuesta de Superior a su queja, puede presentar una queja a la Comisi?n do Servicios Humanos de la Salud de Texas (HHSC) llamando a la linea gratuita 1-866-566-8989. Si desea presentar su solicitud por escrito, envieta a: La Comisic?m de Servicios Humanos de la Salud de Texas. Health Plan Operations H320, ATTN: Resolution Services, PO. Box 85200, Austin, TX 78708-5200. Tambi?n puede enviar su queja por correo electr?nico a Additional help: Superior can help you with case management. Case management can help you get the services you need and even tell you about other help available to you. You can call Superior at 1-800-783-5386 and ask for information about programs that can help you. If you need help understanding this letter or if you want to learn more. you or your representative can call or write Superior at: Centene Company of Texas. Attn: Appeal Coordinator, 2100 S. lH-35. Suite 200,Austin, TX 78704. 1-877-398-9461. Fax: 1-800-735-2989. We will not be unfair to you if you ?le an appeal, fair hearing or complaint. Sincerely, Superior Medical Management cc: Care Pro Home Health Inc Dr. Heidi Kloster Roman Ayuda adicional: Superior puede ayudarlo con la administraci?n de casos. La administracion de casos puede ayudarlo a recibir ios servicios que necesita incluso informarle sobre otro tipo de ayuda disponibie. Puede llamar a Superior al 1- 800-783-5386 solicitar informaci?n sobre los programas que pueden ayudarlo. Si necesita ayuda para entender esta carta si quiere saber mas al respecto, usted su representante pueden ilamar escribir a Superior HealthPIan a: Centene Company of Texas, AIA: Appeal Coordinator, 2100 S. lH~35, Suite 200, Austin, TX 78704. 1-877-398-9461, Fax: 1-866-918-2266, 1-800-735-2989. No Io trataremos injustamente por haber solicitado una apelacion. una audiencia imparcial presentar una queja. Atentamente. Superior Medical Management Legal Services for Low-income Texans I Servicios Legales Gratuitos Texas Rio Grande Legal Aid Texas Rio Grande Legal Aid 1 688-988-9996 Texas Rio Grande Legal Aid serves the following countieslTexas Rio Grande Legal Aid presta servicios en los siguientes condados: Aransas, Atascosa, Bandera, Bastrop. Bee, Bexar, Blanco, Brewster, Brooks, Bumet, Caldwell. Calhoun, Cameron, Cornal, Crockett, Culberson, DeVi?tt, Dimmit, Duval, Edwards, El Paso, Frio, Gillespie, Goliad, Gonzales, Guadalupe, Hays, Hidalgo, Hudspeth, Jackson, Jeff Davis, Jim Hogg, Jim Wells, Karnes, Kendall, Kennedy, Kerr, Kimble, Kinney, Kleberg, La Salle, Lavaca, Live Oak, Llano, Mason, Maverick, McMullen. Medina, Nueces, Pecos, Presidio, Real, Reeves, Refugio, San Patricio, Starr, Sutton, Terrell, Travis, Uvalde, Val Verde, Victoria. Webb, Willacy, Williamson, Vt?lson, Zapata and Zavala. Lone Star Legal Aid 1-800-733-8394 Lone Star Legal Aid serves the following countiesILone Star Legal Aid presta servicios en los siguientes condados: Anderson, Angelina, Austin, Bell, Bosque, Bowie, Brazoria, Brazos, Burleson, Camp, Cass, Chambers, Cherokee, Colorado, Coryell, Delta, Falls, Fayette, Fort Bend, Franklin, Freestone, Galveston, Gregg, Grimes, Hamilton, Hardin, Harris, Harrison, Henderson, Hill, Hopkins, Houston, Jasper, Jefferson, Lamar, Lampasas, Lee, Leon, Liberty, Limestone, Madison, Marion, Matagorda, McLennan, Milam, Montgomery, Morris, Nacogdoches, Navarro, Newton, Orange, Panola, Polk, Rains, Red River, Robertson, Rusk, Sabine, San Augustine, San Jacinto, Shelby, Smith, Titus, Trinity, Tyler. Upshur, Van Zandt, Walker, Waller, Washington, Wharton and Wood. Legal Aid of North West Texas Legal Aid of North West Texas serves the following arealeegal Aid of North West Texas presta servicios en los sigientes condados: Abilene 1-800-933-8591 Midland 1-800-926?5630 Amarillo 1-800-955-6808 Odessa 1-800-955-1207 Brownwood 1-325-646-8659 Plainvievv Dallas 1-214-748-1234 San Angelo 1-800-284-5180 Denton 1-800?955-1407 Waxahachie 1-866-614-3344 Fort Worth 1?800-394-9734 Weatherford 1-800-967-6708 Lubbock 1?800-933-4557 Wichita Falls 1-800-926?5542 McKinney 1-800-906-3045 Midland 1?800-926-5630 superior 2100 mess Sons 200 Auatui TX mat. August 23. 2015 DASHON MORRIS 3340 SILVER CREEK DR TX 75181 Re/Asunto: private Duty Nursing (PDN) tea hours per week I Servicios de enienneria privados Request received oni Soliciiud recioide el: 7/17/2015 FileNoJExpedieulsN": Member/Patient name/Momma de enliado/pecrente. DASHDN MORRIS Member/patient DOB/Fecha do nacrrniento. 05/02/2015 Member/Patient ID noJN' de identificaoion dei Miembro' RaquesleilSolicitanle' Caro Pro Home Health inc Requested Starr Daie/Feeira de inicio eoiictteda; 07/17/2016 Dear DASHON MORRIS: We got your appeal on 3/19/2016. From what you said. we believe this is your appeal: Vou requested a iut appeal tor We reoeived the elinieai inionnetion submitted the appeal. ii you have any other inionnatien you would like to have considered. please submit it. However, this appeal doee not meet the criteria ior test appeal. it will be processed as a etandard so day eppe . We will look into your appeal ans send you an answer in writing. We will mail II within 30 days The appenl decision will be made by a doctor who has not reviewed the case More and who is not supervised by a dado! who reviewed Ihe case before. Appeal "momma: Your appeal will be oompleied within 30 days aner we receive your appeal request The 30 days can be increased by 14 more days You or someone acting lot you can ask ior this extension. We can also ask ior an extension. A letter would be sent io you iiwe need an extension The will tell you why we need more time in make a oecrsron, in orderier us to extend thetime irama you have to tell us you agiee. You have the right to: File a lair hesnng File a complaint Get a tree copy oi the orttena used to make the decision. Ask ior a tree copy oi your case file. Your file might include medical records and any other inionnation. Send written comments or information that is important to your case Gel someone to act in your place. 'rhat person could be a Member oi your lamily. a friend. a lawyer or a doctor. You must authorize this person to act in your piece. . Get legal services. You may quality ior tree or low cost legal servlaes avaiiahle in your area, A list oi legal aid Providers that may be able to help you a included this letter Loot at the page with lhe title. 'Legal Services ior Law--income Texans'. She-groomer: no 5 ism/rm r/r/ vie/lice: rot/i I341 'rn new/9w on in m5 is Company August 23, 2016 supe?or healihplan?. Estimado/a DASHON MORRIS: Recibimos su apelaci?n para el servicio solicitado. Por lo que nos indico. creemos que esta es su apelaci?n: Usted solicito una apelacion rapida para el servicio denegado. Sin embargo. esta apelaci?n no oumple los cntenos para una apelacion rapida. Sera procesada como una apelacion estandar de 30 dias. Analizaremos su apelacion lo enviaremos una respuesta por escrito. Lo enviaremos dentro de 30 dias. La decisiOn respecto a la apelacic?m sera tornada por un m?dico que no ha revisado el caso antes qui?n no es supervisado por un m?dico que reviso el caso antes. Plazo para la revision de la apelacion: Su apelacion se completara en un plazo 30 dies despu?s de que recibamos su solicitud de apelaci?n. Los 30 dias puede incrementarse en 14 dies mas. Usted alguien aotuando en su nombre puede pedir esta extensic'm. Nosotros tambi?n podemos pedir una extension. Se le enviaria una carta si necesitamos una extensi?n. La carta Ie indicara por que necesitamos mas tiempo para tomar una decision. Para que podamos extender el plazo de tiempo. usted nos debe indicar que esta de acuerdo. Usted tiene el derecho a: . Solicitar una audiencia imparcial: Presentar una queja. - Obtener una copia gratuita de los criterios que fueron utilizados para tomar 1a decisi?n. Solicitar una copia gratuita de su expediente. Su expediente puede incluir registros m?dicos cualquier otro tipo de informacion. Enviar comentarios informaci?n por escrito que sean importantes para su caso. - Coordinar para que aiguien Ie represente. Esa persona podria ser un miembro de su familia. un amigo, un abogado 0 un m?dico. Debe autorizar a esta persona para actuar en representacion suya. . Obtener servicios legales. Usted puede cali?car para servicios Iegales gratuitos 0 de bajo costo disponibles en su area. Se inciuye con esta carta una lista de proveedores de asistencia legal que podrian ayudarle. Consulte la pagina con el titulo "Servicios legales para texanos de bajos ingresos". How to file a Fair Hearing: if you disagree with Superior?s decision, you have the right to ask for a Medicaid Fair Hearing from the Health and Human Services Commission (HHSC). You may represent yourself at the Fair Hearing. or name someone else to be your representative. This could be a doctor, relative, friend, lawyer or any other person. You may name someone to represent you by calling us or writing a letter to us with the name of the person you want to represent you. if you want to ask for a Fair Hearing, you can contact us by calling the Appeals Coordinator at 1-877-398-9461. You can fax or mail your request to us. Use the address for the Appeals Coordinator at the bottom of the next paragraph. If you want to challenge a decision made by us, you or your representative must ask for the Medicaid Fair Hearing by 10/20/2016. If you do not ask for the Fair Hearing by this date, you may lose your right to a Fair Hearing. To ask for a Fair Hearing, you or your representative should write or call us Superior at: Centene Company of Texas, Attn: Appeal Coordinator, 2100 S. lH-35. Suite 200,Austin. TX 78704. 1- 877-398-9461, Fax: 1-800-735-2989. If you believe that waiting for a Fair Hearing will seriously jeopardize your life or health, or your ability to attain, maintain or regain maximum function, you or your representative may ask for an expedited Fair Hearing by writing or calling us. To qualify for an expedited Fair Hearing through HHSC, you must ?rst complete Superior?s internal appeals process. If you ask for a Fair Hearing by 8/1/2016, you may be able to keep getting any service or bene?t that is being terminated, suspended, or reduced by Superior, at least until the ?nal hearing decision is made. If you do not request a Fair Hearing by this date, the service or bene?t will be terminated, suspended, or reduced. If you lose your Fair Hearing appeal, we may be able to recover the costs of providing the service or bene?t to you while the appeal was pending. If you ask for a Fair Hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most hearings are held by telephone. You can also contact the HHSC hearings officer if you would like the hearing to be held in-person. During the hearing, you or your representative can tell why you need the service or why you disagree with our action. You have the right to examine, at a reasonable time before the date of the Fair Hearing, the contents of your case ?le and any documents to be used by us at the hearing. Before the hearing, we will send you all of the documents to be used at the hearing. HHSC will give you a ?nal decision within 90 days from the date you asked for the hearing. Continuing Services: To continue services: . You must request an appeal or a fair hearing by the later of 10 days from the date of the original denial letter, or the day that the letter says your services will be reduced or will end. You must say in your request that you want to continue services. The denied services must have been previously authorized. The time period covered by the original authorization must not have ended. If the above are met the services will continue until any of the following happen: . You cancel the fair hearing. . Your fair hearing is denied. . The time period covered by the original authorization has ended. como solicitar una audiencia imparcial: Si no esta de acuerdo con la decision de Superior, usted tiene el derecho de pedir una audiencia imparcial de Medicaid a la Comisi?n de Salud Servicios Humanos (Health and Human Services Commission, HHSC). En la audiencia imparcial, usted se puede representar a si mismo nombrar a otra persona para que sea su representante. Esta podria ser un m?dico, pariente, amigo. abogado cualquier otra persona. Tambi?n puede nombrar a alguien que ie represente llamandonos escribi?ndonos una carta con el nombre de la persona que desea que le represente. Si desea solicitar una audiencia imparcial, puede contactarnos de forma gratuita llamando al Coordinador de Apelaciones al 1-877-398-9461. Puede remitirnos su solicitud por fax 0 por correo. Use Ia direccion del Coordinador de Apelaciones en la parte inferior del parrafo siguiente. Si desea impugnar una decision hecha por nosotros, usted su representante debera solicitar la audiencia imparcial de Medicaid antes de 90 dias de la fecha indicada en la carta de denegacion. Si no pide la audiencia imparcial antes de esta fecha, usted puede perder su derecho a una audiencia imparcial. Para pedir una audiencia imparcial. usted su representante debe escribirnos llamarnos a Superior HealthPIan: Centene Company of Texas. Attn: Appeal Coordinator, 2100 S. IH-35, Suite 200.Austin, TX 78704. 1-877-398-9461, Fax: 1600-7352989. Si piensa que el esperar por una audiencia imparcial pondra seriamente en peligro su Vida salud su capacidad para alcanzar, mantener recuperar sus funciones maximas, usted 0 SU representante puede solicitar una audiencia imparcial acelerada escribi?ndonos llamandonos. Para cali?car para una audiencia imparcial acelerada a trav?s de HHSC, primero debe completar el proceso de apelaci?n interno de Superior. Si usted solicita una audiencia imparcial antes del d?cimo dia de la fecha indicada en la carta de denegaci?n la fecha de vigencia de la denegaci?n, usted podra seguir recibiendo cualquier servicio bene?cio que se est? ?nalizando, suspendiendo reduciendo por parte de Superior, al menos hasta que se tome la resolucidn de la audiencia ?nal. Si usted no solicita una audiencia imparcial antes de esta fecha, el servicio bene?cio sera terminado. suspendido reducido. Si pierde su apelacion de audiencia imparcial, podremos recuperar Ios costos de prestacion del servicio bene?cio mientras la apelaci?n est? pendiente. Si usted pide una audiencia imparcial, usted recibira un paquete de informaci?n que le indicara la fecha. hora lugar de la audiencia. La mayoria de las audiencias se llevan a cabo por telefono. Tambi?n puede contactar al funcionario de audiencias de HHSC si desea que la audiencia sea en persona. Durante la audiencia, usted su representante puede indicar por qu? necesita el servicio por qu? no esta de acuerdo con nuestra medida. Usted tiene el derecho de examinar, en un plazo razonable antes de la fecha de la audiencia imparcial, el contenido del archivo de su caso Ios documentos que seran utilizados por nosotros en la audiencia. Antes de la audiencia. Ie enviarernos todos los documentos que seran utilizados en la audiencia. La HHSC Ie dara una decisidn ?nal dentro del lapso de 90 dias a partir de la fecha en que pidio la audiencia. Servicios continuados: Para Iograr Ia continuidad de los servicios: . Usted debe solicitar una apelacion una audiencia imparcial antes de la fecha mas tardia entre 10 dias a partir de la fecha de la carta original de negacion 0 el dla en que la carta indique que sus servicios seran reducidos terminados. Debe indicar en su solicitud que usted desea continuar los servicios. Los servicios denegados deben haber sido autorizados previamente. No debe haber ?nalizado el periodo de tiempo cubierto por la autorizaci?n original. Si se cumplen Ios requisitos anteriores, Ios servicios continuaran hasta que ocurra cualquiera de las siguientes situaciones: Usted cancela Ia apelaci?n la audiencia imparcial. - Su apelaci?n audiencia imparcial es denegada. - Finaliza el periodo de tiempo cubierto por la autorizacion original. How to ?le a complaint: You can call Superior toll-free at 1?800-783-5386 to tell us about your problem. You can also ?le a complaint through our website. Go to Click on "Contact Us" in the top right corner of the page. You can also use Superior's complaint form. A copy of the complaint form can be printed from Superior's website. You can mail the form to: Centene Company of Texas, ATTN: Complaints, 2100 South lH-35, Suite 200 Austin, TX 78704. You can also fax your form to 1-866-683-5369. Complaint time frame: We will send you a letter 5 days after we get your complaint to let you know we got it. Superior will have an answer to your complaint within 30 days of the date you submit your complaint. Other Options: You may not agree with our answer to your appeal. If you are not satis?ed, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free to 1-866-566-8989. If you would like to make your request in writing, send it to: Texas Health and Human Services Commission, Health Plan Operations H320, Resolution Services, P.O. Box 85200, Austin, TX 78708?5200. Also, you can send your complaint in an email to If you need help understanding this letter or if you want to learn more, you or your representative can call or write Superior at: Centene Company of Texas, Attn: Appeal Coordinator, 2100 S. lH-35, Suite 200,Austin, TX 78704. 1-877-398-9461, Fax: 1-800-735-2989. We will not be unfair to you if you ?le an appeal, fair hearing or complaint. Sincerely, Superior Medical Management cc: Care Pro Home Health Inc Dr. Heidi Kloster Roman C6mo presenter una queja: Puede llamar a Superior sin costo at 1-800-783?5386 para hacernos saber acerca de su probiema. Tambi?n puede presenter una queja a trav?s de nuestro sitio web. Visite Haga clic en "Contactenos" en la esquina superior derecha de la pagina. Tambi?n puede usar el forrnulario de quejas de Superior. Puede imprimir una copia del fomtulario de quejas disponible en el sitio web de Superior. Puede enviar el forrnulario por correo a: Centene Company of Texas, ATTN: Complaints/Quejas. 2100 South IH-35, Suite 200 Austin, TX 78704. Tambi?n puede enviar el forrnulario por fax al 1-866-683-5369. Plazos para la revision de la queja: Le enviaremos una carta 5 dias despu?s de haber recibido su queja para hacerle saber que nos ha llegado. Superior respondera su queja dentro de los 30 dias siguientes a la fecha que usted presento su queja. Otras opciones: Usted podria no estar de acuerdo con nuestra respuesta. Si no esta satisfecho con la respuesta de Superior a su queja, puede presenter una queja a la Comision de Servioios Humanos de la Salud de Texas (HHSC) ilamando a la linea gratuita 1-888-566-8989. Si desea presenter su soiicitud por escrito. enviela a: La Comisi?n de Servicios Humanos de la Salud de Texas, Health Plan Operations - H320. ATTN: Resolution Services, PO. Box 85200, Austin, TX 78708?5200. Tambi?n puede enviar su queja por correo electronico a Si necesita ayuda para entender esta carta si quiere saber mas al respecto, usted su representante pueden llamar escribir a Superior a: Centene Company of Texas. Appeal Coordinator, 2100 S. lH-35. Suite 200. Austin, TX 78704. 1-877-398-9461, Fax: 1-866-918-2266, TTY: 1-800-735-2989. No lo trataremos injustamente por haber solicitado una apelaci?n, una audiencia imparcial presentar una queja. Ate ntamente. Superior Medical Management name: tvtutuus. unsnutv uuanluA/LVU uenuer: male Member ID: -- Age: I 311?: Cement: Tcxas Foster Cate Dallas Appellant Contaet into Add re Appellant Contact tutu - Phone: Appellant Contact into - Fax: n/a Provider Contact Infu ame: n/a Provider Contacl Infn Address: n/a Provider Can (at! [life - Phone: tl/a Provider Contact Info - FIX: tl/a Substance OtAppeal: Denial ofPtivate Duty Nursing (PDN) Continuation Ofservim: No - Not Requested Denial Notificntion: letter sent 5/05/2016 internal appeal upheld 5/31/2016 Provided: Fax number to send in signed request Follow Up Required: task created for appeal queue Additional Inn): coverage veri tied in Amysis Note: -- FH request for Private Duly Nursing (PDN) 168 houts rweek . approved I 19 hours per week called in by foslet mother Linda Badawo As per Linda she basically wants the ratio explained to her she cannot understand how only 1 nurse for 2 people is possible. She seemed to get upset because i could not answer her questions. I had to explain to her that we did not have any clinical capability nor did we create the authorizations. I let her know that i could set up the hearing but it would be based oif the hours notjust the ratiu. she voiced understanding when i let her know that a medical director would be on Ihe call. explained the FH process to member: I. Done overthe phone. 2. Scheduled by the state 3. Packet not sent until it is scheduled. 4. FHO has 90 days to make final decision. 5. Right to a representative. 6. 1 the request in writing and that they were welcome to add any penincnt details. 7. verified lh: address and phone number. 8. gave the fax number for the appeals dept to send written request by Martinez. Lucy Note Type: Fair Hearing Note Category: Admin Note Encounter Due: 06/15/2016 Encounter Date: 06/! 5/2016 Encounter Type: itearing Summary Tiers ID: 1750703 Evidence Packet 1750703 Page 171 of 21S LUCMARTINEZ. Fri. June 24. 2016 at 09:55 AM 2 of 4 Name: MORRW DO 05/02/2015 Gender: Male Member ID: Ag . BEEP: Ccmene HealthPian Texas Foster Care Dallas Fri, June 17. 2016 at 09:20 AM by Davis. Antonio Nate Type: Generic Appeal Note vz Note Category: Admin Note Encounter Date: 06/17/2016 Appeal Type; Level 1 Note: 0P0566150775~received call from provider Meredith Martin regarding the slatus oran appeal (or private duty nursing. Informed the appeal was denied on 05-3146. Also informed Meredith the mom initiated a FH on 06-10-16. No filnher aclion needed name ofcailer: Meredith Martin call>>back nu - [7-5137 member id: Tue, lune 21, 2016 at 02:19 PM by Martinez, Lucy Note Type: Fair Healing Note Category: Admin Nore Encounter Date: 06/2 [/2016 Encunnter Date: 06/21/2016 Encounter Type: Fair Hearing Notice Tiers ID: 1750703 Note: 0P0566150775 Hearing Appointment Notification/Updated Alert - Appeal ID A - 08/02/2016 09:00:00 AM. AppealUlD - idelevn. mppellantNamc - Dashon,Morris- ~Conference Cally >>lnltiall Thu, June 23' 2016 at 10:19 AM by Guzman. Evelyn Note Type: Generic Appeal Note v2 Nate Category: Admin Note Date: 06/23/2016 Appeal Type: Note: OP0642034105 - Clinicals received via fax on 06/23/16 for PH. 1 will attach documents and Lask FH coordinator. Viewed Yes Job 465 1 Receive Date/Time 06/22/16 05:05 PM Completion Date/Ti." 06/22/16 05:05 PM File Name Sender ID (T51) 9726135102 Caller ID 9726]}5102 Pages 3 Status ok Status Cude 0000 Status Text All pages in the fax were successfully receiva Connect Time 57 Ewdence Packet 1750703 Page 172 of 215 Fri. June 24' 2016 al 09:55 AM 1 Ar A POLICY AND PROCEDURE DEPARTMENT: DOCUMENT NAME: Protocol for Authorizing Medical Management Private Duty Nursing PAGE: 2 of 5 REPLACES DOCUMENT: APPROVED one: 07 12 RETIRED: EFFECTIVE DATE: 07/12 REVEWED DATE: 07/13; 10/13; 06/14; 02 15- 05/15 PRODUCTS: STAR. REFERENCE NUMBER: TX.UM.10.20 CHIP CHIP RSA, MRSA I treatment that complies with the Texas Health Steps periodicity schedule, or is within 3 months of the extension SOC date, whichever is more frequent (for extensions of PDN services]. - Requires care beyond the level of services provided under a Home Health Skilled Nurse Carer Note: Members under 1 7 years of age must reside with a responsible adult who is either trained to provide nursing or is capable of initiating an identified contingency plan when the scheduled priva! uty nurse is unexpectedly unavailable. MEDICAL RM: Initial Authorizations Private Duty Nursing is co dered medically necessary when the member meets all the following criteria: I Meets all of the general criteria; and I Placement of the nurse in the home is done to meet the medically necessary skilled needs of the member only and not for the convenience of the family or caregiver. And at least one of the following: - Dependent on technology to sustain life; or - Requires ongoing and frequent skilled interventions to maintain or improve health status; nr 0 Delaying skilled intervention directly impacts the health status of the client, due to the risk of sudden decompensation in the absence of direct ongoing nursing care (not observation). Continued Authorization: Ongoing Private Duty Nursing Care is considered medically necessary if all of the initial authorization and general criteria are met, PDN cannot be considered for the primary purpose of providing respite care, childcare, or ADLs for the client, housekeeping services. or comprehensive case management beyond the service coordination required by the Texas Nursing Practice Act Evidence Packet 1750703 Page 178 of 216 POLICY AND PROCEDURE DEPARTMENT: DOCUMENT NAME: Protocol for Authorizing Medical Management Private Duty Nursing PAGE: 1 of 5 REPLACES DOCUMENT: APPROVED DATE: 07/ 12 RETIRED: EFFECTIVE DATE: 07/12 REVIEWED DATE: 07/13; 10/ 13; 06/14; 02/ 15; 06/ 15 PRODUCTS: STAR, REFERENCE NUMBER: TX.UM. 10.20 CHIP, CHIP RSA, MRSA SCOPE: Centene Company of Texas, LP URA (CCTX) Medical Management department PURPOSE: To provide guidelines in processing pre-authorization requests for Private Duty Nursing (PDN) services. POLICY: PDN should prevent prolonged and frequent hospitalizations or institutionalization and provide cost effective and quality care in the most appropriate, least restrictive environment. PDN provides direct nursing care and caregiver training and education. The training and education is intended to optimize client health status and outcomes, and to promote family-centered, community-based care as a component of an array of service options. The Pre-Certi?cation Nurse (PCN) and /or Medical Director will consider requests for PDN based on member?s extent of skilled needs, the complexity of the service, and the caregivers? and/ or medical consenter?s abilities. It is hoped that nursing care may be reduced over time if the member?s medical condition improves or the nursing needs decrease. Prior to initiation of home services, the ordering physician should convey to the member or family what the expectations are regarding the weaning of nursing hours and the eventual termination of these services. GENERAL CRITERIA: To be eligible for PDN services, a member must meet EL the following criteria: . Under 21 years of age - Meets medical necessity criteria for PDN - Have a primary physician who 0 Provides a prescription for PDN that is less than 90 days old, indicating the number of hours per day or week and the duration of the request. 0 Establishes a Plan of Care (POC) 0 Provides documentation to support the medical necessity of PDN services. 0 Provides continuing medical care and supervision of the client, including, but not limited to: . examination or treatment within 30 days (initial requests for PDN services], or Evidence Packet 1750703 Page 177 of 216 POLICY AND PROCEDURE DEPARTMENT: DOCUMENT NAME: Protocol for Authorizing Medical Management Private Duty Nursing PAGE: 3 of 5 REPLACES DOCUMENT: APPROVED DATE: 07/ 12 RETIRED: EFFECTIVE DATE: 07/ 12 REVIEWED DATE: 07/ 13; 10/ 13; 06/14; PRODUCTS: STAR, REFERENCE NUMBER: TX.UM.10.20 CHIP, CHIP RSA, MRSA ?Note: Clients whose only SN need is the provision of education for self- administration of prescribed subcutaneous (SQ), intramuscular (IM), or intravenous (IV) injections will not qualify for PDN services. Nursing hours for the sole purpose of providing education to the client and caregiver may be considered through intermittent home health SN visits. Amount and Duration of PDN Prior authorizations for more than 16 hours per day are n_ot issued to a single, independently-enrolled nurse. Requests for prior authorizations of PDN must always be commensurate with the client?s medical needs. Requests for changes in services must re?ect changes in the client?s condition that affect the amount and duration of PDN. The length of the prior authorization is determined on an individual basis and is based on the goals and timelines identi?ed by the physician, provider, and the member or a responsible adult but may not exceed 90 calendar days. TRANSITION TIME (1 0 Day Notification RULE ?35 7. 1 1) 1. To allow the Medical Consenters time to make arrangements to transition from denied or reduced PDN hours, the previously authorized PDN hours will remain in place for a period of 12 calendar days from the date when the denial letter is sent out. This relaying of information to the Medical Consenter must be documented, along with the effective date. 2. The authorization request will be set up under 2 line items in TruCare. 3. The ?rst line item will have a date span of 12 calendar days from the date when the denial letter is sent out with the previously authorized PDN hours. 4. The second line item will start on day 13 up to 90 calendar days with the new reduced PDN hours. Important Notes: . PDN authorization will only be approved for a maximum of 90 calendar days at a time. - PDN is a benefit for members under 21 years of age. - STAR Health PDN requests will be processed by the designated CM SM following FC.UM.17.20, which also pertains to the determination of the appropriate home nursing ratios when multiple FC members reside in the same house. Evidence Packet 1750703 Page 179 of 216 POLICY AND PROCEDURE DEPARTMENT: DOCUMENT NAME: Protocol for Authorizing Medical Management Private Duty Nursing PAGE: 4 of 5 REPLACES DOCUMENT: APPROVED DATE: 07/ 12 RETIRED: EFFECTIVE DATE: 07/ 12 REVIEWED DATE: 07/13; 10/ 13; 06/14; PRODUCTS: STAR, REFERENCE NUMBER: TX.UM.10.20 CHIP, CHIP RSA, MRSA PCN may refer member to waiver programs or adjunct services e. Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS), Personal Care Services (PCS) to meet member?s non-skilled care needs and help maximize member?s outcomes. Member or Medical Consenter is responsible for calling in the referral; SM may assist in the process or provide pertinent information regarding waiver programs or adjunct services/ available resources. REFERENCES: HHSC Uniformed Managed Care Manual chapter 3.22 version 2015 Texas Medicaid Provider Procedures Manual: Vol. 2 Children?s Handbook 10 Day Noti?cation RULE ?357. 11 Bailey KL. Establishing private duty in a Medicare world. Caring. 1998; 27, 29- 3 1. Lulavage A. RN-LPN teams: Toward unit nursing case management. Nurs Manage. 1991; Creighton H. Private duty nursing: Part I - Reimbursement issues. Nurs Manage. 1988; 26. TX.UM.05 Timeliness of UM Decisions and Noti?cations TX.UM. 10.35 Physician?s Peer to Peer Policy FC.UM. 17.20 PDN Review and Member to Nurse Ratio Determination TX.UM.26 Electronic and Verbal Signature Policy DEFINITIONS: Skilled Nursing - means assessments, judgments, interventions, and evaluations of interventions requiring the education, training, and experience of a licensed nurse. Evidence Packet 1750703 Page 180 of 216 POLICY AND PROCEDURE DEPARTMENT: DOCUMENT NAME: Protocol for Authorizing Medical Management Private Duty Nursing PAGE: 5 of 5 REPLACES DOCUMENT: APPROVED DATE: 07/ 12 RETIRED: EFFECTIVE DATE: 07/ 12 REVIEWED DATE: 07/13; 10/13; 06/14; PRODUCTS: STAR, CHIP, CHIP RSA, MRSA REFERENCE NUMBER: TX.UM. 10.20 REVISIONS: DATE Updated ?Product Type? by adding MRSA and deleting Chip 7/ 13 Perinate, Health Texas, Medicare Advantage and 881. Added general criteria requirements. Deleted and updated speci?c criteria regarding hour limitations. Updated PA work process. Updated References. Updated signatories. Update authorization work process and reference. 10/ 13 Deleted ?requires continuous, skillful observations, judgments, 06/ 14 and interventions to correct or ameliorate the member?s health status? under initial authorization criteria. Added the verbal order work process under authorization process. Corrected some grammatical errors. Updated references, de?nitions and signatories. Removed work process and imbedded in attachment section. 02/ 15 Added policy to reference list. Added PDN information under Policy section. Edits and additions 06/ 15 made to Medical Necessity Criteria. Days associated with TAC reference, speci?ed as calendar days. Removed work process attachment and placed in separate document. Updated De?nition and Reference list. POLICY AND PROCEDURE APPROVAL The electronic approval retained in Compliance 360, Centene's management software, is considered equivalent to a physical signature. Director of Utilization Management: Senior Medical Director: Date: Date: Vice President of Medical Management: Date: Chief Medical Of?cer: Date: Evidence Packet 1750703 Page 181 of 216 SERVICES HANDBOOK MARCH 2016 2.13 Private Duty Nursing 2.13.1 Enrollment Home health agencies may enroll to provide PDN under CCP. RN 3 and licensed vocational nurses LVNs) may enroll independently to provide PDN under CCP. Home health agencies must do all of the following: - Com plywith provider participation requirements for home health agencies that participate in Texas Medicaid . Comply with mandatory reporting of suspected abuse and neglect of children or adults . Maintain written policies and procedures for obtaining consent for medical treatment for clients in the absence of the parent or guardian . Comply with all requirements in this manual Independently-enrolled RNs and LVNs must be enrolled as providers in CCP and comply with all of the following: . The terms of the Texas Medicaid Provider Agreement . All state and federal regulations and rules relating to Texas Medicaid . The requirements of this manual, all handbooks, standards, and guidelines published by HHSC Independently enrolled RNs and LVNs must also: . Provide at least 30 days? written notice to clients of their intent voluntarily to terminate services except in situations of potential threat to the nurse?s personal safety. . Comply with mandatory reporting ofsuspected abuse and neglect ofchildren. - Maintain written policies and procedures for obtaining consent for medical treatment for clients in the absence ot'ihe parent or guardian. Independently enrolled RNs must: . Hold a current license from the Texas Board of Nursing BON) or another compact state to practice as an RN. . Agree to provide services in compliance with all applicable federal, state, and local laws and regula- tions, including the Texas Nursing Practice Act. - Comply with accepted professional standards and principles of nursing practice. Independently enrolled LVNs must: . Hold a current license from the Texas BON to practice as an LVN. . Agree to provide services in compliance with all applicable federal, state, and local laws and regula- tions, including the Texas Nursing Practice Act. . Comply with accepted standards and principles ofvocational nursing practice. . Be supervised by an RN once per month. The supervision must occur when the LVN is present and be documented in the client?s medical record. Refer to: Subsection 2.1.2. ?Enrollment? in this handbook for more information about CCP enrollment procedures. 2.1 3.2 Services, Benefits. and Limitations Medicaid clients who are birth through .20 years ofage are entitled to all medically necessary PDN services and home health SN services. cr'r ONLY - cor-raicirr 2015 M?rliEMdennar?aertt 3325591703 Page 182 Of 216 SERVICES HAN DBOO MARCH 2016 PDN is nursing services, as described by the Texas Nursing Practice Act and its implementing regula- tions, for clients who meet medical necessity criteria listed below and who require individualized, continuous, skilled care beyond the level ofSN visits provided under Texas Medicaid (Title XIX) Home Health Services SN. Nursing services are medically necessary under the Following conditions: . The requested services are nursing services as de?ned by the Texas Nursing Practice Act and its implementing regulations. - The requested services correct or ameliorate the client?s disability, physical or mental illness, or condition. Nursing services correct or ameliorate the client?s disability, physical or mental illness, or condition when the services improve, maintain, or slow the deterioration of the client's heath status. There is no third party resource (TPR) ?nancially responsible for the services. Medically necessary nursing services may be either PDN services or home health SN services, depending on whether the client?s nursing needs can be met on a per-visit basis. When documentation does not support medical necessity for PDN services, services maybe available on an intermittent or partatime basis through home health SN. Intermittent visits may be delivered in interval visits of up to 2.5 hours per visit and must not exceed a combined total of three visits per day. A part-time basis is an SN visit that is provided forless than eight hours per day for any number of days per week. Part-time visits may be continuous up to 37.5 hours per day and must not exceed a combined total of three 2.5 hour visits. SN visits may be provided on consec- utive days. PDN must be ordered or prescribed by a physician and provided by an RN, LVN, or a licensed practical nurse (LPN). Professional nursing provided by an RN, as de?ned in the Texas Nursing Practice Act, means the perfor- mance ofan act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of'the principles ofbiological, physical, and social science, as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription ot?therapeutic or corrective measures. Professional nursing involves: - The observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings ot'a person who is ill, injured, infirm. or experiencing a change in normal health processes. . The maintenance of health or prevention of illness. . The administration of a medication or treatment as ordered by a physician, podiatrist. or dentist. . The supervision of delegated nursing tasks or teaching of nursing. - The administration. supervision. and evaluation of nursing practices, policies, and procedures. . The performance of an act delegated by a physician. . Development of the nursing care plan. Vocational nursing, as defined in the Texas Nursing Practice Act, means a directed scope of nursing practice, including the performance of an act that requires specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing. The term does not include acts of medical diagnosis or the prescription ot?therapeutic or corrective measures. Vocational nursing involves: . Collecting data and performing focused nursing assessments of the health status of an individual. . Participating in the planning of the nursing care needs oi?an individual. car over - copvrnon'r 2013 AMERICAN $159303 Page 183 Of 216 SERVJCES HANDBOOK MARCH 2016 . Participating in the development and modi?cation of the nursing care plan. . Participating in health teaching and counseling to promote, attain, and maintain the optimum health level ofan individual. - Assisting in the evaluation of an individual?s response to a nursing intervention and the identifi- cation of an individual?s needs. - Engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse?s experience, continuing education, and demonstrated competency. Professional and vocational nursing care consists of those services that must, under state law, be performed by an RN or LV as de?ned by the Texas Nursing Practice Act ?301.002. These services include observation, assessment, intervention, evaluation, rehabilitation, care and counseling. and health teaching, and which are further defined as nursing services in 42 CPR ??409.32, 40.9.33, and 409.44. - In determining whether a service requires the skill of a licensed nurse, consideration must be given to the inherent complexity of the service. the condition of the client. and the accepted standards of medical and nursing practice. . The fact that the nursing care can be, or is, taught to the client or to the client?s family or friends does not negate the skilled aspect of the service when the service is performed by a nurse. . If the service could be performed by the average nonmedical person. the absence of a competent person to perform it does not cause it to be a nursing service. . If the nature of a service is such that it can safely and effectively be performed by the average nonmedical person without direct supervision of a licensed nurse, the services cannot be regarded as nursing care. . Some services are classified as nursing care on the basis ofcomplexity alone intravenous and intramuscular injections or insertion of catheters), and if reasonable and necessary to the treatment of the client?s illness or injury, would be covered on that basis. In some cases, however, the client?s condition may cause a service that would ordinarily be considered unskilled to be considered nursing care. This would occur when the client's condition is such that the service can be safely and effectively provided only by a nurse. - A service that, by its nature, requires the skills of a nurse in order for it to be provided safely and effectively. continues to be a skilled service even if it is taught to the client, the client?s family, or other caregivers. PDN should prevent prolonged and frequent hospitalizations or institutionalization and provide cost- effective and quality care in the most appropriate, least restrictive environment. PDN provides direct nursing care and caregiver training and education. The training and education is intended to optimize client health status and outcomes, and to promote family-centered. community?based care as a component of an array of service options. A request must include documentation from the provider to support the medical necessity of the service, equipment, or supply. CCP is obligated to authorize all medically necessary PDN to promote indepen- dence and support the client living at home. PDN cannot be considered for the primary purpose of providing respite care, childcare, or ADLs for the client. housekeeping services, or comprehensive case management beyond the service coordination required by the Texas Nursing Practice Act. cp'r ONLY . comment 2015 AMERICAN MddEVlde?GBi-?Ra?kets ?1719501703 Page 184 Of 216 CHILD HANDBOOK MARCH 2016 Claims for PDN services must be submitted to TMHP as follows: Procedure Code Independently Enrolled Maximum Fee T1000 with modi?er TD or TE 15 minutes Home Health Agencies T1000 with modi?er TD or TE 15 minutes 15 minutes ,15 minutes Note: lndependently-enrolled Llr?Ns must use the TB modi?er, anal independently-enrolled RNs must use the TD modifier. Home health agencies that provide PDN services for clients with a tracheostomv or clients who are ventilator-dependent receive additional reimbursement. Providers must bill using procedure codes T1000, T1002, or T1003 with the UA modi?er and one of the following diagnosis codes: Diagnosis Codes J9500 l9501 I9502 19504 Z930 229911 Z9912 Z430 I95850 Because of the nature of the service being provided, some billing situations are. unique to PDN. These billing requirements are as follows: All hours worked on one day must be billed together, on one detail. even if they involve two shifts. For example. it?Nurse A works 7 am. to 11 am. and then returns and works 7 pm. to 11 p.1n.. services must be billed for 8 hours (32 15-minute units) on one detail for that date of service. An individuallv-en rolled nurse will not be reimbursed for more man 16 hours of PDN services in one day. PDN mayr be delivered in a provider to client ratio other than one-on-one. An RN or LVN may provide PDN services to more than one client over the span of the day as long as each client?s care is based on an individualized POC, and each client?s needs and POC do not overlap with another client?s needs and FCC. Only the time spent on direct PDN for each client is reimbursed. Total PDN billed for all clients cannot exceed an individual provider's total number of hours at the POS. A single nurse may be reimbursed for services to more than one client in a single setting when the following conditions are met: The hours for PDN for each client have been authorized through CCP. Only the actual ?hands?on? time spent with each client is billed for that client. The hours billed for each client do not exceed the total hours approved for that client and do not exceed the actual number ofhours for which services were provided. Example: lfthe prior authorized PDN hoursjor Client A is four hours, Client 8 is six hours, and the actual time spent with both clients is eigl-it hours. the provider must billfor the actual one?on-one time spent with each client, not to exceed the. client?s prior authorized hours or total hours worked. 1? would be acceptable to billfour hours for Client A and four hoursjor Client B, or three hours for ClientA aud?ve hours for Client B. It would not be acceptable to bill ?ve hoursfor Client A and three hours for Client B. It would be acceptable to bill ten hours if the nurse actually spent ten hours onsite pro viding prior authorized PDN services split as four hours Client A and six hours for Client 8. A total often hours cannot be billed if the nurse worked only eight hours. ceronvr . COPYRIGHT 20:5 MllilEVldB?GBhR?Gk-els Page 1 85 Of 216 SERVICES HANDBOOK 2016 For reimbursement purposes, PDN must always be submitted with P05 2 (home) regardless of the setting in which services are actually provided. PDN may be provided in any of the following settings: . Client?s home . Client?s school . Client?s daycare facility PDN that duplicates services that are the legal responsibility of the school districts are not reimbursed. The school district, through the SHARS program. is required to meet the client?s SN needs while the client is at school; however. if those needs cannot be met by SHARS or the school district, documen- tation supporting medical necessity may be submitted to the CCP with documentation that nursing services are not provided in the school. ?Responsible adult? means an individual who is an adult, as defined by the Texas Family Code, and who has agreed to accept the responsibility for providing food. shelter, clothing, education, nurturing, and supervision for the client. Responsible adults include. but are not limited to: biological parents, adoptive parents. foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage. A responsible adult of a minor client or a client's spouse may not be reimbursed for PDN even if the responsible adult is an enrolled provider or employed by an enrolled provider. PDN is subject to retrospective review and possible recoupment when the medical record does not document that the provision of PDN is medically necessary based on the client?s situation and needs. The PDN provider?s record must explain all discrepancies between the service hours approved and the service hours provided. For example. the parents released the provider from all responsibility for the service hours or the agency was not able to staff the service hours. The release of provider responsibility does not indicate the client does not have a medical need for the services during those time periods. 2.13.2.1 PDN Provided During a Skill Nursing Visit for TPN Administration Education For clients who receive PDN services and who also require administration education. the inter~ mittent SN visits may be reimbursed separately when the SN services are for client and caregiver training in TPN administration and the PDN provider is not an RN trained in the administration of TPN. and the PDN provider is not able to perform the function. PDN and SN must not be routinely performed on the same date during the same time period. PDN and SN will not be considered for reimbursement when the services are performed on the same date during the same time period without prior authorization approval. If the SN visit for TPN education occurs during a time period when the PDN provider is caring for the client, both the PDN provider and the nurse educator must document in the client?s medical record the skilled services individually provided including, but not limited to: . The start and stop time of each nursing providers specialized task(s) . The client condition that requires the performance of skiiled PDN tasks during the SN visit for PN education . The skilled services that each provided during that time period Both the intermittent skilled nurse visit and the PDN services provided during the same time period may be recouped if the documentation does not support the medical necessity ofeach service provided. cp'r ONLY covviuou?r ans AMERICAN MddEVld??G?hRa?ik-ets Page 1 86 Of 216 CHI LD KEN ERV HANDBOOK MA RCH 2016 2.13.2.2 Criteria 2.13.221 Client Eligibility Criteria To be eligible for PDN services. a client must meet all the following criteria: Be birth through 20 years of age and eligible for Medicaid and "Fl-[Steps . Meet medical necessity criteria for PDN . Have a primary physician who must: - Provide a prescription for PDN. . Establish 3 FCC. . Provide documentation to support the medical necessity of PDN services. . Provide continuing medical care and supervision of the client, including, but not limited to, examination or treatment within 30 calendar days prior to the start of PDN services, or exami- nation or treatment that complies with the THSteps periodicity schedule, or is within six months of the PDN extension SOC date, whichever is more frequent (for extensions services). This requirement may be waived based on review of the client's speci?c circumstances. Note: The physician visit may be waived when a diagnosis has already been established by the physician, and the client is under the continuing care and medical supervision of the physician. A waiver is valid for no more than 365 days, and the client must be seen by hisr?her physicim-i at least once every 365 days. The waiver must be based on the physician?s written statement that an additional evaluation visit is not medically necessary. This documentation must be maintained by the physician and the provider in the client?s medical record. . Provide specific written, dated orders for the client who is receiving continuing or ongoing PDN services. . Require care beyond the level ofservices provided under Texas Medicaid (Title XIX) Home Health Services Clients who are birth through t7 years of age must reside with a responsible adult who is either trained to provide nursing care or is capable of initiating an identi?ed contingency plan when the scheduled private duty nurse is unexpectedly unavailable. 2.i 3.2.2.2 Medical Necessity PDN is considered medically necessary when a client has a disability, physical, or mental illness, or chronic condition and requires continuous, skillful observations, judgments, and interventions to correct or ameliorate his or her health status. Documentation submitted for a request for PDN must address the following questions: . Is the client dependent on technology to sustain life? . Does the client require ongoing and frequent skilled interventions to maintain or improve health status? . Will delaying skilled intervention impact the health status of the client? if so, how will the health status be affected? . Deterioration ofa chronic condition . Risk ofdeath . Loss of function . Imminent risk to health status due to medical fragility car 01er . comment 2015 AMERICAN MEIlEvlde?oa?amkets d1-7b50l703 Page 1 87 Of 216 SERVICES HANDBOOK 3016 2.13223 Place of Service (POS) PDN is based on the need for skilled care in the client?s home; however, these services may follow the client and may be provided in accordance with 42 CFR M4030. The POS must be able to support the client?s health and safety needs. It must be adequate to accom- modate the use, maintenance, and cleaning of all medical devices, equipment, and supplies required by the client. Necessary primary and backup utilities, communication, tire, and safety systems must be available at all times. 2.13.224 Amount and Duration of PDN The amount and duration of PDN must always be commensurate with the client's medical needs. Requests for services must re?ect changes in the client?s condition that affect the amount and duration 2.13.3 Prior Authorization and Documentation Requirements A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply. A CNM, CNS, NP, or PA may sign all documentation related to the provision of private duty nursing services on behalt?of the client?s physician when the physician delegates this authority. All signatures must be current. unaltered, original, and handwritten; computerized or stamped signa~ tures will not be accepted. All documentation must be maintained by the requesting PDN provider. The PDN provider may be asked to submit additional documentation to support medical necessity. Requests for nursing services must be submitted on the required Medicaid authorization forms and include supporting documentation. The supporting documentation must: . Clearly and consistently describe the client?s current diagnosis, functional status, and condition. . Consistently describe the treatment throughout the documentation. - Provide a suf?cient explanation as to how the requested nursing services correct or ameliorate the client?s disability, physical or mental illness. or condition. When a provider receives a referral for PDN, the provider must have an RN perform a nursing assessment of the client within the client?s home environment. This assessment must be performed before seeking prior authorization for PDN, with any request for PDN recertificaiion, or any request to modify PDN hours. The assessment must demonstrate the following: - Medical necessity for PDN. . Safety of providing care in the prOposed setting. - Il?birth through 17 years of age, the client resides with a responsible adult who is either trained to provide nursing care or is capable of initiating an identified contingency plan when the scheduled private duty nurse is unexpectedly unavailable. - ?Responsible adult? means an individual who is an adult, as de?ned by the Texas Family Code, and who has agreed to accept the responsibility for providing food. shelter, clothing, education, nurturing, and supervision for the client. Responsible adults include, but are not limited to: biological parents, adoptive parents, foster parents, guardians. court-appointed managing conservators, and other family members by birth or marriage. . An identi?ed contingency plan is a structured process designed by the responsible adult and the PDN provider. by which a client will receive care when a scheduled private duty nurse is unexpectedly unavailable, and the responsible adult is unavailable, or is not trained to provide the nursing care. The identi?ed responsible adult must be able to initiate the contingency plan. ONLY . comment 2015 salesman MddlEtVld??G?rR?Gliets 3171591703 Page 1 88 Of 216 SERVICES HANDBOOK 2016 The existing level of care and any additional health-care services including the Following: SHARS. MDCP, OT, PT, ST, primary home care and case management services. Note: Services provided under these programs do not prevent a client from obtaining all medically necessary services. Certain school services are provided to meet education needs, not medical needs. Records related to a client?s Individuals with Disabilities Education Act services are con?dential records that clients do not have to release or provide access to. When an RN completes a client assessment and identi?es a medical necessity for ADLS or health-related functions to be provided by a nurse, the scope services may include these ADLs or healthqelated functions. Note: CCP does not review or authorize PDN based on partial or incomplete docmnentation. PDN must be prior authorized. and requests for PDN must be based on the current medical needs of the client. The following criteria are considered for PDN prior authorization: . The documentation submitted with the request is complete. . The requested services are nursing services as de?ned by the Texas Nursing Practice Act and its implementing regulations. - The explanation of the client?s medical needs is sufficient to support a determination that the requested services correct or ameliorate the client?s disability, physical or mental illness, or chronic condition. - The client?s nursing needs cannot be met on an intermittent or part-time basis through Texas Medicaid (Title XIX) Home Health Services skilled nursing services. . There is no TPR ?nancially responsible for the services. Only those services that CCP determines to meet the medical necessity criteria for PDN are reimbursed. Before CCP determines the requested nursing services do not meet the criteria, the TMHP Medical Director contacts the treating physician to determine whether additional information or clari?cation can be provided that would allow for the prior authorization of the requested PDN. If the TMHP Medical Director is not successful in contacting the treating physician or cannot obtain additional infor- mation or clari?cation, the TMHP Medical Director makes a decision based on the available information. Providers must obtain prior authorization within three calendar days of the SOC for services that have not been prior authorized. During the prior authorization process, providers are required to deliver the requested services from the SOC date. The SOC date is the date agreed to by the physician, the PDN provide r, and the client or responsible adult and is indicated on the submitted POC as the SOC date. Note: CCP does not prior authorize an SOC date earlier than seven calendar days before contact with TMHP. Prior authorizations for more than 16 hours per day are not issued to a single, independently-enrolled nurse. Requests for prior authorizations of PDN must always be commensurate with the client?s medical needs. Requests for services must reflect changes in the client?s condition that affect the amount and duration of PDN. The length of the prior authorization is determined on an individual basis and is based on the goals and timelines identi?ed by the physician, provider, and client or responsible adult. PDN is not prior autho- rized for more than six months at a time. PDN is not prior authorized under any of the following conditions: a The client does not meet medical necessity criteria. . The client does not have a primary physician. cp?r ONLY coertucur 2m AMERICAN MddEVld??GBbRa?kels $159303 Page 189 Of 216 SERVICES HANDBOOK MARCH 2016 . The client is 21 years of age or older. . The client?s needs are within the scope of services available through Texas Medicaid (Title XIX) Home Health Services SN or home health agency services because the needs can be met on a part- time or intermittent basis. Intermittent SN visits for clients who receive PDN and who require TPN administration education may be considered for separate prior authorization if: . The PDN provider is not an RN who has been appropriately trained in the administration of TPN, and the PDN provider is not able to perform the function. - There is documentation that supports the medical need for an additional skilled nurse to perform TPN. The SN services may be prior authorized only for the client and caregiver who will be trained in TPN administration. Clients whose only SN need is the provision of education for seltladrninistration of prescribed subcuta~ neous (SQ). intramuscular (IM), or intravenous (1V) injections will not qualify for PDN services. Nursing hours for the sole purpose of providing education to the client and caregiver may be considered through intermittent home health SN visits. 2.13.3.1 Retroactive Client Eligibility Retroactive eligibility occurs when the effective date ofa client?s Medicaid coverage is before the date that the client?s Medicaid eligibility is added to eligibility file, which is called the ?add date.? For clients with retroactive eligibility, prior authorization requests must be submitted after the client's add date and before a claim is submitted to TMHP. For services provided to Medicaid clients during the client?s retroactive eligibility period the period from the effective date to the add date, prior authorization must be obtained within 95 days from the client's add date and before a claim for those services is submitted to TMHP). For services provided on or after the client?s add date. the provider must obtain prior authorization within three business days of the date of service. The provider is responsible for verifying eligibility. The provider is strongly encouraged to access the Automated Inquiry System or exMedConnect to verify eligibility frequently while providing services to the client. If services are discontinued before the client's add date. the provider must still obtain prior authorization within 95 days of the add date to be able to submit claims. 2.13.3.2 Start of Care (SOC) The SOC is the date that care is to begin, as agreed on by the family, the client's physician. and the provider, and as listed on the POC and the CCP Prior Authorization Request Form. Providers are responsible for determining whether they can accept the client for services. Once the provider accepts a client for service and accepts responsibility for providing PDN, the provider is required to deliver those services beginning with the SOC date. Providers are responsible for a safe transition ofservices when the authorization decision is a denial or a reduction of services. Providers are required to notify the physician and the client's family on receipt of an authorization, a denial, or a change in PDN. Providers must submit complete documentation no later than three business days from an SOC date to obtain initial coverage for the SOC date. Note.- Texas Medicaid Title XIX.) Home Health Senwi'ces does not authorize an SOC date earlier than three business days before contact with Trill-1P. cp'r ONLY - 2015 AMERICAN M??Ev?moenRaakets 3171251017 03 Page 190 Of 216 SERVICES HANDBOOK MARCH 2016 For PDN recerti?cation, CCP must receive complete documentation no Eater than three business days before the SOC date. It is recommended that recertification requests be submitted up to 30 days before the current authorization ends. During the prior authorization process for initial and recerti?caiion requests, providers are required to deliver the requested services from the SOC date. 2.13.3.3 Prior Authorization of lnitiai Requests Compieted initial requests must be received and dated by CCP within three business days of the SOC. The request must be received by CCP no later than 5 pm, Central Time, on the third day to be considered received within three business days. If a request is received more than three business days after the SOC, or after 5 Central Time. on the third day, authorization is given for dates of service beginning three business days before receipt of the completed request. An initial PDN prior authorization request requires all of the following: - CCP Prior Authorization Request form . Home Health Plan of Care (POC) form - CCP Nursing Addendum to Plan of Care form All forms must be completed, signed. and dated by the primary physician within 30 calendar days prior to the SOC. The RN who completes the assessment and the client, or responsible adult, must also sign the CCP Nursing Addendum to Plan of Care form. The CCP Nursing Addendum to Plan of Care form must include all of the following: . Updated problem list . Updated rationale! summary page . Contingency plan - 24?hour daily care ?owsheet . Signed acknowledgement initial requests for PDN may be prior authorized for up to 90 days. Refer to: Nursing Addendum to Plan of re 0n the TMHP website at '3 i on the website at on the TMHP website at 2.13.3.4 Authorization for Revision of Current Services The provider may request a revision at any time during the authorization period if medically necessary. The provider must notify TMHP at any time during an authorization period if the client?s condition changes and the authorized services are not commensurate with the client?s medical needs. Completed requests for revision of PDN hours during the current authorization period must be received by CCP within three business days of the revised SOC. The request must be received by no later than 5 Central Time, on the seventh day to be considered received within three business days. if a request is received more than three business days after the revised SOC or after 5 pm, Central Time, on the third day, authorization is given for dates of service beginning three business days before receipt of the completed request. The revised PDN prior authorization request must include all of the following: - CCP Prior Authorization Request form . Home Health Plan ot'Care (POC) form cur ONLY COPYRIGHT 2015 AMERICAN MQEVM?arBaGl?ets 3153559303 Page 191 Of 216 SERVICES HANDBOOK h-U-illCi-I 3016 . CCP Nursing Addendum to Plan of Care form The provider is responsible for ensuring that the physician reviews and signs the FCC within 30 calendar days of the start date of the revised authorization period or more often if required by the client?s condition or agency iicensure. The provider must maintain the physician-signed POC in the client?s medical record. PDN providers should not submit a revised POC unless they are requesting a revision. Revision requests for PDN may be prior authorized up to six months. If all necessary documentation is not submitted for a six-month authorization. an authorization for a period up to three months may be approved. Revisions to a current certi?cation must fall within the certi?cation period. If the revision extends beyond the current certi?cation period. new authorization documentation must be submitted to Refer to: Addendum to Pian of ("are (CCP) on the TMHP website at uwv.tinlip.gnin. CRCP Prior Authorization Request Form on the TMHP website at immatmh neon). Home Health Plan of Care POC) on the MHP website at 2.13.3.5 Recertifications of Authorizations Completed extension requests must be received and dated by CCP at least seven calendar days before, but no more than 30 days before, the current authorization expiration date. The request must be received by CCP no later than 5 pm. Centrai Time, on the seventh day, to be considered received within seven calendar days. Ifa request is received less than seven calendar days before the current authorization expiration date, or after 5 Central Time. on the seventh day. authorization is given for dates of service beginning no sooner than seven calendar days after the receipt of the completed request by CCP. Recerti?cations may be prior authorized for up to six months. The following criteria are required for recerti?cation authorization: . The client has received PDN services for at least three months. . No significant changes in the client?s condition have occurred for at least three months. . No signi?cant changes in the client?s condition are anticipated. - The client?s responsible adult. physician, and provider agree that a authorization is appropriate. The recerti?cation process includes the following: . Ali required documentation for PDN services (including the Physician POC, the Nursing Addendum to POC, and the CCP Prior Authorization Request Form) - CCP Private Duty Nursing six-Month Authorization form, which must be signed and dated by the primary physician. nurse provider, and client, or responsible adult The nursing care provider is responsible for ensuring that a new Physician POC is obtained within 30 calendar days ofthe authorization period ending and maintained in the client?s record. Providers should not submit interim POCs to CCP unless requesting a revision. The nursing care provider must notify CCP at any time during the authorization period if the client?s condition and need for SN care signi?can tly changes. The nursing care provider may request a revision From at any time during the authorization period if the client's condition requires it. All authorization timelines apply to recertitications also. our outv - nus AMERICAN sit?ldEVl?-B??arP-ia?l?ets 31571-591703 Page 1 92 Of 216 SERVICES HANDBOOK Refer to: Nursing Addendum to Plan of Care on the TMHP website at 3 rm on the TMHP website at 2.13.3.6 Termination of Authorization An authorization may be terminated when the: . Client is no longer eligible for CCP or Medicaid. . Client no longer meets the medical necessity criteria for PDN. a POS can no longer accommodate the client?s health and safety. . Client or responsible adult refuses to comply with the service plan and compliance is necessary to ensure the client?s health and safety. 2.13.3.7 Client and Provider Notification When PDN is approved as requested. the provider receives written notification. The provider is respon- sible for notifying the client/family and the physician of the authorized services. CCP noti?es the client and provider in writing when the following instances occur: . PDN is denied. . PDN hours authorized are less than the hours requested on the POC. . PDN hours are modi?ed hours are requested by the week but are authorized by the day). . CCP receives incomplete information from the provider. . Dates of service authorized are different from those requested. . The provider is responsible for notification and coordination with the physician and family. 2.13.3.8 Authorization Appeals Providers may appeal denials or modi?cations of requested PDN with documentation to support the medical necessity of the requested PDN. A request for prior authorization must include documentation from the provider to support the medical necessity of the service. equipment, or supply. Appeals must be submitted to CCP with complete documentation and any additional information within two weeks of the date on the decision letter. if changes are made to the authorization based on this documentation. CCP goes back .no more than three business days for initial or revision requests and no more than seven calendar days for recerti?cation requests when additional documentation is submitted. The client or responsible adult is noti?ed ofany denial or modi?cation of requested services and is given information about how to appeal decision. Documentation forms have been designed to improve communication between providers and CCP- The forms are available in English and Spanish. All documentation must be submitted together, and requests are not reviewed until all documentation is received. If complete documentation is received at CCP by 3 p.1n.. Central Time, a response is returned to the provider within one business day. Complete documentation for initial, revision. recerti- fication. and extension requests for PDN authorizations include all of the following: on the TMHP website at mvw.tmhp,corn. on the TMHP website at mamhnxom. . Nursing Addendum to i?lan ol?Care on the TMHP website at cr?r ONLY - zuis snemcan MildEVldB?GBrPia?lEGls ?1371501703 Page 193 Of 216 MARCH 2016 CHI SERVICES HANDBOOK MARCH 2016 2.13.3.9 CCP Prior Authorization Request Form The CCP Prior Authorization Request Form must be completed. signed, and dated by the physician. When PDN services are ordered, by signing the form the physician attests and certi?es the client's medicai condition is suf?ciently stable to permit safe delivery of PDN as described in the plan of care. All requested dates of service must be included. 2.13.3.10 Home Health Plan of Care (POC) The POC must be recommended, signed, and dated by the client?s primary physician. A POC must meet the standards outlined in the 42 CFR ?484.18 related to the written POC. The primary physician must review and revise the POC, in consultation with the provider and the responsible adult, for each prior authorization, or more frequently as the physician deems necessary or the client?s situation changes. Pursuant to 42 CFR ?484.18, the FCC must include the following elements: . All pertinent diagnoses . Client?s mental status - Types of services requested including amount, duration, and frequency . Medical equipment needed . Prognosis - Rehabilitation potential . Functional limitations Activities permitted . Nutritional requirements . Medications. including dose, route, and frequency . Treatments, including amount, duration, and frequency - Safety measures needed . instructions for a timely discharge from service, if appropriate . Date the client was last seen by the physician . Other medical orders . Start- and end-of-care dates . Responsible adult or identi?ed contingency plan Note: Coverage periods do not coincide necessarily with calendar weeks or months but. instead. cover a number of services to be scheduled between a start and end date that is assigned during the prior mithorizarion period. A week includes the day ofthe week on which the prior authorization period begins and con tinues for seven days. For example, if the prior authori- zation starts on a Thursday, the prior authorization week runs Thursday through Wednesday. The number ofnursing hours authorized for a week must be contained in that prior authorization week. Hours billed in excess of those uuthorizedfor the PAN week are subject to recoupment. 2.13.3.11 Nursing Addendum to Plan of Care (CCP) Form . The Nursing Addendum to Plan of Care (CCP) Form addresses PDN eligibility criteria, nursing care plan summary, health history summary, 24-hour schedule, and the rationale for the hours requested. err ONLY coprmoi-rr 2015 AMERICA-N MddlEiVld??GBhR?erts 3315593 03 Page 1 94 0f 21 6 SERVICES HANDBOOK MARCH 2016 The following is a description of the nursing care plan summary: The nursing care summary is not a complete nursing care plan. Information must be client-focused and detailed. The problem list must re?ect the reasons that nursing services are needed. The problem list is not the nursing care plan. Providers must identify two-to-four current priority problems from their nursing care plan. The problem does not need to be stated as a nursing diagnosis. The problems listed must focus on the primary reasons that a licensed nurse is required to care for the client. Other attached documents are not accepted in lieu of this section. The Goals must relate directly to the problems listed and be client-speci?c and measurable. Goals may be short- or long~termi however, for many clients who receive PDN, the goals generally are long-term. The Outcomes are the effects of the provider's nursing interventions and must be measurable. Generally. these are more short-term than goals. For initial requests, list expected outcomes. Extension requests should note the results of nursing interventions. The Progress must be viewed as a ?yardstick? or continuum on which progress toward goals is marked. Initial requests must state expected progress for the authorization period. Extension requests must list the progress noted during the previous authorization period. it is recognized that all progress may not be positive. The addendum must summarize the client's health problems relating to the medical necessity for PDN. The addendum must clearly communicate a picture of the client?s overall condition and nursing care needs. The summary of recent health history is imperative in determining whether the client?s condition is stable or if new nursing care needs have been identi?ed. This section gives the PDN provider an opportunity to describe the client?s recent health problems, including acute episodes of illness, hospitalizations. injuries, and so on. The summary should create a complete picture of the client?s condition and nursing care needs. The summary may cover the previous 90 days. even though the authorization period is 60 days; however, the objective of the summary is to capture the client?s recent health problems and current health priorities. This section should not be merely a list of events. This section is the place to indicate the frequency ot'nursing interventions if they are different from the physician?s order on the FCC. such as. the order may be for a procedure to be PRN (Pro Re Nata "As Needed?), but it is actually being performed every two hours. The addendum must include the rationale for increasing, decreasing, or maintaining the level of PDN and must relate to the client?s health problems and goals. The addendum must include the provider's plan to decrease hours or discharge from service if appropriate). 2.13.3.11.1 The client?s 24-Hour Daily Schedule All direct-care services must be identi?ed. it is understood that the schedule may change, as the client?s needs change. CCP does not have to be noti?ed of changes in the schedule except as they occur when a PDN recerti?cation is requested. 2.13.3.12 Responsible Adult or Identified Contingency Plan Requirement For clients who are birth through 17 years of age, the client must reside with an identi?ed responsible adult who is either trained to provide nursing care or is capable ofinitiating an identi?ed contingency plan when the scheduled private duty nurse is unexpectedly unavailable. err outr - copriuoi-n' 2015 auralcan MEISEVWBEQEKBE 11.35017 03 Page 1 95 Of 216 SERVICES HANDBOOK MARCH .2016 . ?Responsible adult? means an individual who is an adult. as defined by the Texas Family Code, and who has agreed to accept the responsibility for providing food. shelter, clothing, education, nurturing, and supervision for the client. Responsible adults include, but are not limited to: biological parents, adoptive parents, foster parents, guardians, court-appointed managing conser- vators, and other family members by birth or marriage. . An identi?ed contingency plan is a structured process. designed by the responsible adult and the PDN provider, by which a client will. receive care when a scheduled private duty nurse is unexpectedly unavailable, and the responsible adult is unavailable, or is not trained, to provide the nursing care. The responsible adult must be able to initiate the identified contingency plan. The responsible adult's signature must be on the form acknowledging: . Information about CCP PDN has been discussed and received. . PDN may change or end based on a client?s need for nursing care. . PDN is not authorized for the primary purpose of?providing respite. childcare, ADLs, or housekeeping. . All requirements have been met before seeking prior authorization for PDN. . The responsible adult has participated in the development of the and the nursing care plan for the client. - Emergency plans have been made and are part of the client's care plan. . The client or responsible adult agrees to follow the physician's POC. 2.13.3.13 Special Circumstances Prior authorization may be considered for PDN services provided in a school or day care facility, at the request of the family, provided the client requires the requested amount of PDN services in the home. Prior authorization may be considered for PDN services provided in a hospital, SN facility, or interme- diate care facility for the mentally retarded, or special care facility with documentation from the facility showing it is unable to meet the SN needs of the client and the services are medically necessary. These facilities are required by licensure to meet all the medical needs of the client. 2.13.3.14 Documentation of Services Provided and Retrospective Review Documentation elements that are routinely assessed for compliance in retrospective review of client records include, but are not limited to, the required documentation noted previously, as well as the following: . All entries are legible to people other than the author. dated (month, day, year, time), and signed by the author. . Each page of the record documents the client's name and Medicaid identification number. . Client assessment time is documented at the beginning of each shift. . All nurses? arrival and departure times are documented with signature and time in the narrative section of the nurses? notes. . Entries in the nursing ?owsheet or narrative notes must be dated and timed every I to 2 hours and must include the following: - The client?s condition. . The name ofthe medication, dose. route, time given, client response, and other pertinent infor- mation is recorded when medication is administered. cp'r ONLY . coevalun?r ears AMERICAN sidilEVld??G?hPaa?l?ets 3571591703 Page 196 Of 216 CH I LD RENS SE RVICES HAN DBOOK - The name of treatment. time given, route or method used, client response, and other pertinent information is provided when treatments are administered. . The amount, type, times given, route or method used, client response, and other pertinent info r~ mation is provided when feedings are administered. . The POC and documentation of services correlate with and reflect medical necessity for the services provided on any given day. - A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply. . Client?s arrival or departure from the home setting is documented with the time of arrival, departure, mode of transportation, and who accompanied the client. . Documentation of teaching the client or the client?s responsible adult includes the length of time, the subject of the teaching, the understanding of the subject matter by the person receiving the teaching, and other pertinent information. Supervisory visits include speci?cs of the visit. . If a client is receiving SN services through another program or service in addition to CCP. such as MDCP, each provider?s shift notes designate specifically which type of service they are providing during that shift. 2.13.4 Claims Information PDN providers must submit claims for services in an approved electronic claims format or On the appro- priate claim form based on their provider type. Home health agencies must submit claims on the (EMS-1450 paper claim form. Independently enrolled nurses must submit claims on the paper claim form. TMHP does not supply the forms. Refer to: Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1. General Information) for information on electronic claims submissions. Section 6: Claims Filing (Vol. 1, General information) for general information about claims tiling. Subsection 6.5, Paper Claim Filing Instructions? in Section 6, ?Claims Filing? (Vol. J, General Information) for instructions on completing paper claims. Subsection 6.6. (EMS-1450 Paper Claim Filing Instructions? in Section 6, ?Claims Filing? Vol. 1, General In?ammation) for paper claims completion instructions. 2.13.5 Reimbursement {303% services are reimbursed in accordance with TAC ?355.8441. 2.14 Therapy Services (CCP) Occupational therapist, physical therapist, and speech therapist services beyond the limitations of Texas Medicaid and Title XIX Home Health Services are benefits of the for clients who are birth through 20 years of age and who are CCP eligible when: . Therapy is prescribed by a licensed physician. . Documentation of medical necessity supports a condition that requires ongoing therapy or rehabil- itation in the usual course, treatment, and management of the client's condition. in Therapy services are provided by a licensed therapist. . Therapy is provided in one of the following places of service: 0 CORP and ORF cur ONLY - comment 2015 AMERICAN MESEVWBREQKEE Page 197 Of 216 MA RCH 2016 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6/8/ 10 RETIRED: NA EFFECTIVE DATE: 7/1/ 10 6/7/11, 8/22/11, 3/5/12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 SCOPE: Superior Network (SHPN) Medical Management and Service Management Department PURPOSE: To de?ne Service Management?s role in processing PDN requests. WORK PROCESS: 1. Prior Authorization staff receives the pre-authorization request for Private Duty Nursing (PDN) from provider. Prior Authorization staff creates authorization in the member?s electronic record and tasks to for clinical review. 2. Manager of Service Coordination will assign clinical review to a Case Manager for review and completion 3. Assigned Case Manager changes authorization owner 1. Assigned Service /Case Manager/ RN Service Coordinator will review submitted documentation. If request is for retroactive dates of service, authorization will be administratively denied. A task will be sent to TX Denial Team for written noti?cation. 2. Alberto process will be initiated for all requests with incomplete documentation 0 Contact the requesting provider 0 fax the designated letter informing of the required documentation that needs to be submitted. 0 generate an electronic task for 16 business hours from provider noti?cation for follow up. Evidence Packet 1750703 Page 204 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6 10 RETIRED: NA EFFECTIVE DATE: 7/ 1/ 10 6/7/ 1 1, 8/22/ 1 1, 3/5/ 12; 3/2013, 1 1/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 If the required documentation is not received within sixteen (16) business hours of the request, the SM will: 0 contact the member/ medical consenter notifying request cannot be acted upon without the documentation from the provider 0 Generate and mail the designated letter, including a copy of letter sent to the provider. 0 Generate an electronic task for 7 calendar days of member noti?cation for follow up. a If the required documentation is not received within seven (7) calendar days of the letter, SM will forward the request to the medical adviser for review and determination, noting that the request was incomplete and the Alberto process has been completed but missing documentation has not been received. Medical Advisor will complete the review and make a determination. - SM will complete authorization based upon Medical Advisor?s determination. If the determination is a denial or reduction in service, a task will be sent to TX Denials. SM will call member/ medical consenter, and requesting provider informing them of the denial or reduction of the requested service. 4. If member attends school, SM will call the school district to determine if school district participates in the SHARS program. a If district states that they do not participate in SHARS, SM will request written documentation 0 If district states that they do participate in SHARS but cannot provide for the member?s needs, SM will request written documentation 5. SM reviews submitted documentation to determine medical necessity has been met; determination of appropriate ratio will be veri?ed as follows: A. Ratio Member to Nurse Indicators with requesting physician approval: 1. 1:1 Unstable or acute conditions and co-morbidities to include but not limited to: a. New onset of mechanical ventilator or new to caregiver. Evidence Packet 1750703 Page 205 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6/8 10 RETIRED: NA EFFECTIVE DATE: 7/1/10 6/7/11, 8/22/11, 3/5/ 12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 b. New onset of tracheostomy or new to caregiver C. d. New Transition from O2 therapy to a ventilator New Transition from O2 therapy to or CPAP New placement change with condition that requires continuous skilled intervention and skilled assessment Newly prescribed frequent IPPB treatments g. Newly prescribed infusion therapy or TPN continuous h. enteral or nasogastric feedings Extensive wound care Epidermolysis bullosa) 2. 2:1 Chronic conditions that require continuing assessment and skilled intervention to include but not limited to: a. b. e. Member on mechanical ventilator, or CPAP greater than 60 days and stable. Infusion therapy or TPN continuous enteral or nasogastric feedings older than 60 days c. Frequent IPPB treatments older than 60 days and stable. d. Both members are located in the same house. No contraindication for a 2:1 ratio 3. 3: 1 Chronic condition with stable co-morbidities Without exacerbation within 90 days and requires frequent assessment and skilled intervention to include but not limited to: a. Continuous enteral feedings b. Round the clock neb treatments c. Wound care (1. All members are located in the same house. e. No contraindication for a 3:1 ratio B. Exceptions to 2:1 or 3:1 Ratio: 1. For health and safety reasons, the Private Duty Nurse may not be assigned more than one (1) vented member. 2. Reportable transmittable or communicable diseases as de?ned by CDC Evidence Packet 1750703 Page 206 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6 10 RETIRED: NA EFFECTIVE DATE: 7/1/10 6/7/11, 8/22/11, 3/5/ 12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 6. Initial requests, requests for increase in hours or ratio, or if clinical information submitted does not support the medical necessity of requested PDN hours and or ratio, SM will: 0 forward Medical Advisor for review - initiate the pre-appeals process if medical necessity is not supported, Medical Director may also initiate Pre-Appeals process upon his review of the clinical information 7. The Medical Director will make the determination based on clinical information received. If the determination is a possible denial, reduction in the number of PDN hours, or an increase in the member to nurse ratio status, the peer to peer review and pre-appeals processes will be followed. 8. If the determination is an approval, the SM will: 0 update and complete referral authorization in the member?s electronic record. 0 notify the medical consenter and provider of the determination 0 fax authorization noti?cation letter to the provider 0 document PDN prior authorization review in the member?s electronic record. 9. If the determination is a denial or partial approval, the SM will: 0 update and complete referral authorization in the member?s electronic record. - notify MC CW and requesting provider of determination. - ensure that transition time of 12 days is allowed with previously approved PDN hours remaining in place from the date of determination - generate an electronic task to the Denial team to process the denial 10. In order to provide continuity of care for members transitioning from TMHP, SHP will authorize approved PDN services upon receipt of the TMHP authorization. (SM will follow authorization process). a The initial review process will be followed by SM upon the ?rst renewal request Evidence Packet 1750703 Page 207 of 216 WORK PROCESS DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6/ 8 10 RETIRED: NA EFFECTIVE DATE: 7/ 1/ 10 6/7/ 1 1, 8/22/ 1 1, 3/5/12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 LREFERENCES: ETTACHMENTS: 7 SM Service Management PDN Private Duty Nursing 24 hr log 24 hr daily ?ow sheet regarding care provided for member to include PDN and family/ caregiver coverage and coverage from other resources. Alberto Process- Noti?cation process for obtaining incomplete information submitted by HH provider to support medical necessity of requested PDN services. Skilled Nursing - means assessments, judgments, interventions, and evaluations of interventions requiring the education, training, and experience of a licensed nurse. Medical Necessity? TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2, 3.9.2.2.3 Documentation submitted for a request for PDN must address the following questions: Is the client dependent on technology to sustain life? Evidence Packet 1750703 Page 208 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6 10 RETIRED: NA EFFECTIVE DATE: 7/1/10 6/7/11, 8/22/11, 3/5/12; 3/2013, 1 1/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 - Does the client require ongoing and frequent skilled interventions to maintain or improve health status. - Will delaying skilled intervention impact the health status of the client? If so, how will the health status be affected? - Deterioration of a chronic condition - Risk of death 0 Loss of function - Imminent risk to health status due to medical fragility REVISION LOG REVISION DATE Initial Certi?cation Request Process 3 added new process Process 4 added verbiage regarding retro authorization. Process 9 revised verbiage Process #10 added new process Recerti?cation Request Process 3 added new process Process 6 - revised verbiage Process l4 added new process Process 3 16 revised verbiage Added paragraph regarding transition time 10 Day Noti?cation RULE ?357. 1 1 Note section bullet 2 revised verbiage. 4/25/11 4/25/11 4/25/11 Document title changed from PDN Pre?auth Process to PDN Review and Member to Nurse Ratio Determination Process Scope added Medical Management Purpose revised verbiage Initial PDN Certi?cation revised verbiage on process 1,5,9, 1 l, 13, and14 ?Added process 7 and 8 6/8/11 Evidence Packet 1750703 Page 209 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6/8/ 10 RETIRED: NA EFFECTIVE DATE: 7/ 1/ 10 6/7/ 1 1, 8/22/ 11, 3/5/ 12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 PDN Recerti?cation Pre-auth Process Added work process 9 Revised verbiage on process 11, 12, 13, and 15 Added de?nition for skilled nursing. Added HHSC Rider 61 (8B1, item 13, page 202) to the reference 8/ 22/ 1 1 section Initial Certification Process 8, 1, removed ?Frequent oral or 3 /5 12 tracheostomy suctioning 8 or more times in a 24 ?hr period? from criteria list. Recertification - Process 9, 1, a, revised verbiage 3 5 12 Work Process: Initial PDN Certi?cation Request 3 2013 39 6. C. inserted ?forward the request for medical review and determination with notation that the request was incomplete, Alberto process has been completed but missing information has not been submitted.? Removed the word ?team?. Changed wording to If the determination is a denial or reduction in service?; place a courtesy call to the member medical consenter and requesting provider informing them of the denial or reduction of the requested service. 6,7,8,9,16, 17 removed the word ?team? Added 10. SM may initiate the pre-appeals process and create a request for medical review in the member?s electronic record if the clinical information does not support the medical necessity of requested PDN hours, ratio, or if the determination is a possible denial, decrease in the number of requested hours or an increase in the member?to-nurse ratio. The medical director may also initiate the pre-appeals process upon his review of the clinical information. 13. Added SM will generate an electronic reminder to check for the ?nal determination? Work Process: PDN Recerti?cation Pre-Auth Process 6. Added reminder is generated and sent to TX Evidence Packet 1750703 Page 210 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6 I 8 10 RETIRED: NA EFFECTIVE DATE: 7/ 1/ 10 6/7/11, 8/22/11, 3/5/12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 Denials for written administrative denial noti?cation 6 and 8 removed the word ?team? 8. Removed the words ?and pre-appeals? 8.C. changed wording to ?If the documentation information is not provided to the SM within seven calendar days of the letter to the member, SM will forward the request for medical review and determination with notation that the request was incomplete, Alberto process has been completed but missing information has not been submitted. Medical director will complete the review and make a determination. If the determination is a denial or reduction in service, a reminder will be sent to TX Denials to prepare and mail the letter. SM will place a courtesy call to the member/ medical consenter and requesting provider informing them of the denial or reduction of the requested service. 1 1, 12 removed the word ?nurse? 12. Added ?The medical director may also initiate the pre?appeals process upon his review of the clinical information. 14. Changed wording to SM will generate an electronic reminder to check for the ?nal determination?. Initial PDN Certi?cation Request Changed ?reminder? to ?task noti?cation? 1 added ?The assigned Manager of Service Coordination or designee will triage the request for assignment to either Complex Case Management (CCM) or Private Duty Nursing (PDN) team.? #4 added ?from PDN team? 12 added ?and will make the ?nal determination based on?; ?received?; ?process will be followed? #13 removed will generate an electronic Evidence Packet 1750703 Page 211 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6/ 8/ 10 RETIRED: NA EFFECTIVE DATE: 7/ 1/ 10 6/7/11, 8/22/11, 3/5/12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM.17.20 reminder to check for the ?nal determination; if approved? 0 #14 added ?appropriate?, ?staff?, ?appropriate Denial #17 Removed ?apprOpriate drop downs: 0 Note Type Prior Auth I Note Reason Clinical Assessment 0 Event Select the appropriate referral event for the note? PDN Recerti?cation Pre-Auth Process 0 #10 Removed ?using appropriate drop down: Note Type Prior Auth Note Reason Clinical Assessment Event Select the appropriate referral event for the note; Added ?note summary/? a #12 Added ?Adviser? Transition Time #2 changed ?trigger? to ?task reminder? Important Notes 0 Changed wording from authorization Will only be approved for a maximum of 90 days.? to authorization span of coverage for initial PDN requests may be approved for up to 90 days. If member has a chronic condition that require devices or enteral feedings to sustain life and no anticipated change in member?s status within 6 #13 added ?process will be followed #14 Changed ?reminder? to ?task? #15 added ?appropriate denial staff to? #16 added ?note summary Evidence Packet 1750703 Page 212 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6/ 8/ 10 RETIRED: NA EFFECTIVE DATE: 7/1/10 6/7/11, 8/22/11, 3/5/ 12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 mos., the authorization span of coverage may be granted up to 180 days as appropriate. Added PRODUCT TYPE: Foster Care Removed references to ?Complex Case Manager? and throughout document INITIAL PDN CERTIFICATION REQUEST: I changed ?either Complex Case Management (CCM) or Private Duty Nursing (PDN) team? to ?a Service Manager?. 0 Removed RS will attach in the member?s electronic record, the supporting documentation submitted with the Private Duty Nursing (PDN) auth request.? 0 Removed If request is received after the start of care date, the RS will create 2 separate line items with the authorization for retro dates of service and current dates of service.? a 2. Added ?Assigned Service Manager?; removed ?from PDN team?; changed ?member?s electronic record and required? to ?submitted?. a 3. Added ?Request for retroactive?; 4. Changed ?may? to ?will? 0 5. Changed ?missing clinical information and required forms? to incomplete documentation?; added ?as follows:? 0 A. Changed? Return the request to the Medicaid provider with a letter describing? to ?contact the requesting provider and fax the designated letter?; removed ?when possible, SM will contact the Medicaid provider by telephone and obtain the information necessary to complete the prior authorization request?; changed ?reminder? to ?task?; changed ?post? to ?for?; removed ?letter? B. Added ?required?; removed ?information?, removed ?to the Medicaid provider?; removed ?or designated team member?; added ?contact the member/ medical consenter?; ?removed ?will send a 11/2014 Evidence Packet 1750703 Page 213 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6/ 8/ 10 RETIRED: NA EFFECTIVE DATE: 7/ 1/ 10 6/7/11, 8/22/11, 3/5/12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 letter to the member?; changed ?information is provided? to ?has been received from the provider?; removed ?along with? C. Added ?required?; removed ?information?; changed ?provided? to received?; changed ?for? to ?to the?; added ?adviser for?; changed ?with notation? to ?noting?; changed ?information? to ?documentation?; changed ?submitted? to ?received?; changed ?Director? to ?Advisor?. 0 D. Added ?The SM will review the Medical Adviser?s determination and will complete the authorization?; changed ?reminder? to ?task?; removed ?to prepare and mail the letter.? 8. Added ?For initial review, request for increase in authorized hours or ratio?; removed Review including clinical information to support medical necessity criteria for requested hours and appropriate ratio?. Removed ?1 1. If clinical information does not support the medical necessity of requested PDN hours, or if determination is a denial or decreased in number of hours, the assigned will initiate the pre- appeals process.? 10. Removed ?Foster Care?; changed ?Director? to ?Advisor? 11. Added ?If the determination is an approval, the SM will notify the medical consenter and provider of the determination and complete the authorization?; removed ?status?; added ?and send fax authorization noti?cation letter to the provider.? 12. ?changed ?reduction? to ?decrease?; removed ?status?; removed ?and the ordering provider?; changed ?noti?cation? to ?task?; removed ?of the demial?; removed ?appropriate?; changed ?staff? to ?team?; removed ?The appropriate Denial Appeals Coordinator will complete the denial process.? l3, 14. Added ?the?; changed ?auth? to ?authorization? Evidence Packet 1750703 Page 214 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6/8/ 10 RETIRED: NA EFFECTIVE DATE: 7/1/ 10 6/7/11, 8/22/ 11, 3/5/12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 PDN RECERTIFICATION PRE-AUTH PROCESS a Combined 1?5 into 1. Added Request for retroactive authorization may be administratively denied by SM due to late noti?cation. A task is generated and sent to TX Denial Team for written administrative denial noti?cation.? 0 Changed ?missing clinical information and required forms? to ?incomplete documentation which? supports medical necessity of requested PDN hours, the SM will initiate the Alberto process as follows: 0 See wording for Initial PDN Certi?cation Request #5 for changes I 10. Changed ?Director? to ?Advisor? PURPOSE: 0 Removed: ?To provide guidelines in processing the pre-authorization requests for Private Duty Nursing (PDN) services, determination of member to nurse ratio for Private Duty Nursing services and ensure safeguard measures are applied in the determination process; de?ne Service Management?s role in processing the request? 0 Added: ?To de?ne Service Management?s role in processing PDN requests.? WORK PROCESS: Combined sections ?Initial PDN Certi?cation Request? and Recerti?cation Pre-auth Process? Removed Important Notes: - PDN authorization span of coverage for initial PDN requests may be approved for up to 90 days. If member has a chronic condition that requires devices or enteral feedings to sustain life and no anticipated change in member?s status within 6 7/2015 Evidence Packet 1750703 Page 215 of 216 WORK PROCESS DEPARTMENT: DOCUMENT NAME: Service Management, Medical PDN Review and Member to Nurse Ratio Management Determination Process PAGE: 1 of REPLACES DOCUMENT: APPROVED DATE: 6/ 8/ 10 RETIRED: NA EFFECTIVE DATE: 7/1/10 6/7/ 11, 8/22/11, 3/5/12; 3/2013, 11/2013, 11/2014, 7/2015 PRODUCT TYPE: Foster Care REFERENCE NUMBER: FC.UM. 17.20 mos., the authorization span of coverage may be granted up to 180 days as appropriate. . SM may refer member to waiver programs or adjunct services MDCP, HCS, to meet member?s non-skilled care needs and help maximize member?s outcomes. SM may assist in the process or provide pertinent information regarding waiver programs or adjunct services I available resources. Removed Attachments: 0 Provider Letter Incomplete Information . Denial Letter - Incomplete Information No response 7 days 0 Member MC Letter Noti?cation Incomplete Information WORK PROCESS APPROVAL The electronic approval retained in Compliance 360, Centene?s P85P management software, is considered equivalent to an actual signature on paper. Director of Service Coordination Chief Medical Director FC VP of Operations Evidence Packet 1750703 Page 216 of 216 0448316 20:19 FROM-- T-533 F424 Care Pro floral me 2700 W. Pleasant Run Rd, #380. Lancaster, TX 75145' Phone: 972-230-4741 ax 972-230-4745 ORDER TO: W242, DATE: M53211 (N nine of Physician) FROM: PATJENTI MEDICAID 003: 05/02 IZOIS PHYSICIANS 510mm DATE Evidence Packet 1750703 Pa 9 15 of 216 Ou/18/2016 8:3 PM 04-18316 20:19 FROM-- T--533 F-124 Nursing Addendum to Plan of Care of 7 5. "known-199mm: Mus! waned by Ind th- nurse wider. By signing ml: form, In: and tho nun. memga- Discusian um mums GOP PM my Naming amine. XPDN sorvha: mayhu'use, am. away me ma. based on a dlam'l nud tar.th an. PDN 1 not nummzoa bf reams. mm. mm" Mdifly ano' er WWII. All Mull Wm moon": ldfamium Ire met. and WW acumen L5 "(mm-d mus-mm Nursing Caro Plan in? [hit wllmi mew plan: an In. alum- cara piin Ind Mcde Meghan: Mmbau on dinnl': amines, nuphal. ma eqmpmant suppliuam imam-mine. on hawk: We mummy shamans Yhe mumuanihn lure" Wmmugll Him m: Pl!" aim It plumb" by 1M diam's phyliaan. Numwwf heun Santa muse yaw-r sign-me o1 plesaihma amid-r. swan Evidefie'e'figc'fit {V36me Wow?" 0h/19/2016 8:3 PM superior N00 South In 35 Suite zoo Austin, ix 75704 Request tor Clinical Appeal Date: 16 Mly 2016 To: Dr. Heidi anon Fax 214-456-5702 Member name: DASHON MORRIS Anthorinlion it: ON566150775 Member 1m! -- Date a! Binh: 05/02/2015 Service Requested: Private Duty Nursing (PDN) 168 hours per week Requested intormatiou: letter provides an opportunity to submit additioqu documentation above and peyoud what may have ulreedy been submitted. Please submit the following Any other relevant iutormution regarding member's health status ineiuding doeumentation showing the need tor the administration otml or g-mbe medicllions, monitoring for events such as nxygen detsturations or seizures or nebulizer treatments, oral or superneial sucfioning. You may submit additional clinical documentation to support the sppeal request, ifyau wisu liyou have submitted tlie clinical intormation you would like us to review, please disregard this message. ADDITIONAL INFORMATION MUST BE RECEIVED BY 5/23/2016 Send Response to: Clarissa Situentee Appeals Department rax it 866-918-2266 Evidence Packet 1750703 Page 101 of 216 Name: MOW Gender: Male Member 11): Age: BHP: Centene Healthlan Texas Foster Care Dallas Menu ber Notes Tue, May 17, 2016 at 12:02 PM by Davis, Antonio Note Type: Generic Appeal Nme v2 Nut: Category: Admin Nate Encounter Dine: 05/17/2016 Appeal Type: Level 1 Note: OPDS66l50775-receivcd addilional clinical information via fax from Dr. Heidi Ramon on Il1e denial of Privale Duty Nursing (PDN) 168 hours per week. Anacth fax to note, Sent to nurse for rcview, Viewed Yes Job ID 4996 Receive Dam/Time 05/17/16 I 1:l5 AM 05/17/16 11:19 AM File Name i0517l6l92?3157fle Pages I4 Stalus ok Slams Code 0000 Slams Text All pages in lhe fax were successfully received. Connect Time 265 DID Number 8669182266 Fax Port 32 Fax Server Folder ID 5103 Folder Palh Antonio Davis Last Modified 05/17/2016 ":55 AM Note Antonio Evidence Pack-3i 1750703 Page 102 of 216 LUCMARTINEZ. Fri, June 24. 2016 at 09:46 AM i320?) FROM- 214--888-4830 F991 Poem/0022 F-862 CK COVENANT KIDS Box (73083 78003-3035 Phone (817] "$9100 Fax: (317) 5169102 'lo Whom it May Conuem' I am submitting an appeal on behalf 01 foster parent Linda Badawo and foster child Dashon Morris. His DOB is 05/02/16. His soeial Security number Is -- and his Person ID number is Reoenlly Superior decreased his nursing hours In his loeler home. Dashon la placed In the same foster home as his twin sister They are both primary medically fragile babies. Ms. Badawo has been able to have two nurses, one for each child. up until Daehon'a hours were decreased. Dashon has multiple medical appointments and has been hospitaliled on more than one occasion. When Dashon has medical appointments or has to be transported anywhere. his foster parent is unable to transport alone due to his medical needs It his nurse travels with her. there is no longer a nurse in the home to care for his sister. It is a tedious and possibly dangerous prospect to pack up his sister's medical equipment when it is not necessary or she does not have an appointment when he does. I have Included his last month's medical appointments and where he was hospitalized in May. Ms. Badawo Is a single luster parent and wants optimal healthcere lor Deshon. Please feel free to contact me with any further Information you may need. Respectfully Meredith Hoflman CK Family Services Case Manager Evidence Packet 1750703 Pa 149 of216 06/01/2016 I: 8PM 08-01-? 18 13:05 214?888?4830 - . Pt Name: meal/ton childrenshealt?. I Physical Medicine and Rehabilitation )7 '11 ?f Speech Therapy Video ?uoroscopic Swallow Study Flexible Endoscopic Evaluation of Swallowing (FEES) Findings and Reoommondon?ons ?ing Recommendations: 0 Oral feedings LV- Alternative means of nutrition Why {3-111 Wastes of LAM) with: WT Wareglvers NPO (nothing by mouth) ?iet Recommendations: Liquids: mun consistency (to. water. juice) a Half nectar consistency (Le. whole milk, Pediasure) Nectar consistency (Le. fruit metals, tomato juice, smoothie) 0 Honey consistency (Le. milkshake thick, honey) Thickening recipe: Food: Worse consistency (Le. baby food, yogtu-t, applesauce) a Mechanical so? noodles, cooked vegetables, eggs) 0 Crunchy solids (Le. chips, crackers) Solids (Le. meet, fmit) Other: d'n InstructionsModificatio - Bottle nipple Cu or? Spoon .M Other Provide: Pacing Alternate liquids/solids Multiple swallows Positioning: [At Additional strategies: Pl ?iate or continue therapy focusing on in? 1 WM Location: Additional modalities to consider: 0 AM'ttonsI recomme??tonsii'ollow up: Educalion: Results and recommendations of nomination discussed with 22w ho verbalizcd understanding and agreement. Evaluation completed by: MSW Phone 5111! Contact physician if signs of aspiration (choking, and change in respiratory status) are noted with above feeding recommendations. 1535 Medical District Dune Dallas. Texas 75235 to! 214.456.1000 woo Evidence Packet 1750703 Page 150 of 216 06/01/2016 Name: MORRIS. DASHON Member ID: 003:05/02/2015 Gender: Male Age: 1 Blu': Cenlel'le Texas Foster Care Dallas Fri. June 17v 2016 3109:20 AM Note Type: Note Category: Encounter Dale: Appeal Type: Note: by Davie Antonio Generic Appeal Note v2 Admin Note 06/17/2016 Level 1 0P0566 50775-received call from provider Meredith Martin regarding Ihe slams dran appeal for private duty nursing. Informed Meredith the appeal was denied on 05-31-161 Also informed Meredith the mom initiated 3 PH on 06-10-16. No further action needed name of caller: Meredith Martin call-back number: 214--517-5137 member id: Tile. June21,20163t 02:19 PM Nate Type: Note Category: Encounter Date: Encounter Date: Encounler Type: Tiers ID: Note: by Martinez. Lucy Fair Hearing Admin Note 06/21/2016 06/21/2016 Fair Hearing Notice 1750703 0P0566150775 Hearing Appointment Notification/Updated Alert - Appeal 1D . -, 08/02/2016 09:00:00 AM. AppealUID ideleon. ppellanINal-ne - DashunMorris- FHSmings -Conferencc Calu -lnitial . Thu. June 23. 201631 Note Type: Not: Category: Encounter Date: Appeal Type: Nata: by Guzman. Evelyn Generic Appeal Note v2 Admin Note 06/23/2016 0P0642034105 - Clinicals received via fax on 06/23/16 for FH. will attach documents and task FH coordinator. Viewed Yes Job ID 465 1 Receive Dale/Firm 06/22/16 05:05 PM Completion 05/22/16 05:05 PM File Name 60622220849584.1117 Sender ID (181)9726135102 Caller ID 9726135102 Pages 3 Stalus 0k Stalus Code 0000 Status I'ext All pages in the fax were successfully received. Connect Time 57 Evidence Packet 1750703 Page 172 of 216 lung 74 anixtmtu: All A mine: UAMIUN DOM/omen Gender: Male Member ID: -- Age: BHP: Centene Texas Appellant Cantnet lnro - Address: Appellant Contact Inro -- Phone: Appellant Cnntaet Info - Fax: n/a Provider Contact Info Name: n/a Provider Contact Inl'n - Address: n/a Provider Contafl Info - Phone: n/a Provider Contact Info - Fax: n/a Substance or Appeal: Denial of Private Duty Nursing (PDN) Continuation Ol'Services: No - Not Requested letter sent 5/05/2016 lnlemal appeal upheld 5/31/2016 Denial Notifiealio Resources Provided: Fax number to send in signed request Follow Up Required: task created for appeal queue Addition-I Info: coveng verified in Amysis Note: 0F0566150775 FH request for Private Duty Nursing (PDN) 168 hours er week approved 1 19 hours per week called in by foster mother Linda Badawo i As per Linda she basically wants the ratio explained to her she cannot understand how only i nurse for 2 people is possible, She seemed to get upscl because i could not answer her questions. I had to explain to her that we did not have any clinical capability nor did we create the authorizations. I let her know that i could set up the hearing but it would be based hours notjust the ratio. she voiced underslanding when i let her know thal a medical director would be on the call. I explained the PH process to member: 1. Done over the phone. 2. Scheduled by the state 3. Packet not senl until it is scheduled. 4. FHO has 90 days Io make final decision. 5. Right to a representative. 6. I requested the requesl in writing and that they were welcome to add any pertinent details. 7. verified address and phone number. 8. I gave the fax number for the appeals dept to send written request Wed. June [Sr 2016 at [2:31 PM by Martinez, Lucy Note Type: Fair Hearing Note Cltegory: Admin Note Encounter Date: 06/15/2016 Encounter Date: 06/l 5/20l6 Encounter Type: Hearing Summary Tier: 1750703 Note: 0P0565l50775 FH entered into Tiers Tiers ID l7so703 4800 attached Evidence Packet 1750703 Page 171 of 216 LUCMARTINEZ. Fri, June 24, 20l6 3109:55 AM 2 cf 4 Commonly known as: KEMLDG Your dischargeihome resources Enteral Compeny 7 Agency? Enterel SupplIee' EntereI StetIue EnIereI Comment Your dieohergeihome resources Apply 1 application lODIoally 2 times dally Moe! Reoent Value '6o3ir'?'ii?ll?cii?r3'??i" 89? - Imp-n.? 0w .- uonnwu-m-u' unw-pu-IHII- -.- luau-uh - residue; 'ilIlIo'key button. Pump supplies - begs. Pump euppIies - - .. .. -. Mlokey 12 "french 1. 217m formula similee sensitive Most Reoent Value imam .WRespiratory Supplies Concentrator. Heated humidi?er. Nebullzer. Oxygen. Oxygen - pobrieble. Pulse oximeter. Suction machine! supplies. Treeheostomy tu Respiratory Statue Respiratory Comrnent'" 3. 5 blvona and spare 3.0 Bivena trach? Your dieeherg?me resources . Meal Recent Value Private Duty Nursing Number I63 unaware-rod -. . .. I Prlyeie Duty INumiIng stetue ?Eileen: pit-751's Duty Nursing Resume PEN car's Prii 675350-4747 lu' 072350-4744 Comment Your dlooheg?ome mouroee Mosi?eoenweiue ??0le TYPE Heme Thorep py_ Home Health Therapy 'jr'ii?r'npy 2600 Pi-?lone: 214-407-9707 #411: 214-741-3000 . .. . .s . . .. II Therapy DquipIIiIr-ge I I II Therapy. Physical Therapy ..- . {Therein . .Homrtiea'ih .n h- Therapy Therapy smug Existing Your scheduled appointments at Children'e Health for the next 30 days May 111. am 12:00 are Our Children's House Pulmonary with Steven c. Copenhaver. MD 3301 Swiss Avenue Our Children's House Physician Clinic (Our Children's Dallas TX 75204 House) 214-620-9812 Jun 02.2013 -.. Complex Fu with Heidi Roman, MD 1935 Medical District Drive Children's Belles Foster Care (Dallas) Dallas W. 75235 214453-8500 YOU: Til-Du lie? a; . II EDI Home $4712 on Jana..- EXTERNAL I {fa - L1 ?In Discharge Summary Notes PM Discharge Summaries by Rachel Elizabeth Ternan. MD at smote Version 2 of 2 Authon Rachel Elizabeth Ternen. Service: General Pediatrics Author Type: Physician MD Filed: 5I3I2016 7:30 PM Note Time: 6i3f2016 6:02 PM Status: Addendum Editor: Rachel Elizabeth Ternan. MD (Physician) Related Notes: Original Note by Asif Khan. MD (Resident) tiled at 5l3i2016 6:34 PM Discharge Summary - Children's Medical Center of Dallas Patient Name: DaShon Darnell Morris DOB: $212015 mum: 3:15 AM more: some cameraman: Seizure Seizure Seizure Chronic lung disease ?98.41 Hypoglycemia Allergies: No Known Allergies Endocrinology WW: None DaShon Darricil Morris is a 11 m. o. male ear-2526 weaker with complex past medical history including CLD with trash dependence. FDA sip repair. ROP. hearing loss. intrauterine drug exposure. with g-tube dependence. GERD sip Nissan. grade 4 NH. developmental delay. hydrocephalus sip VPS who presents to the ED after having Jerking of all four extremities. found to be hypoglycemic to 23 by EMS. Mom noticed that pt seemed to be crying in his sleep around midnight when she went to start his normal continuous overnight feeds. Pt completed all feeds yesterday (3 bolus feeds during the day). including normal Bpm-me feed. with no issues. Pt then began to jerk all four' extremities while staring ot'i. Mom called EMS. when they arrived. they found blood glucose to be 23. then gave giucagon and 010. Glucose en route was 50. Jerking continued for a total of 30 minutes. and resolved upon arrival to the ED. Once in the ED. glucose was 104. In the ED. pi was started on 010 ?uids and increased to 1.5x maintenance. Blood glucose increased to 160 prior to transfer to the floor. No further jerking or abnormal movements observed in the ED. Mom reports that pt has otherwise been in his usual state of health prior to this event. However. she now feels like he is breathing little faster in the ED and seems to have a cough. No fevers at home. no URI. no vomiting. or note. foster mom has cared for pt since October. As far as she knows. he has never had any seizures. in NovIDec. pt had movements of Jaw during sleep. He had an EEG after that. which did not show show any seizure activity. These movements have not recurred. admission Physical ?533: Vitals: BP 97:58 I Poise 165 5 Tampisrc} 36. 7 (Tempo. r?el) i Resp 35' Hi 70 cm (27 5318.16 I Hi: 45. 5 cm {1131"} I 100% Genorai: Atari. active mate in no acute distress. Wait-nourished. weii~deveiopsd. Calm during exam. I is race . so as Lwcir?wgr? I?t'leW? .l-iaaleeck: Normocephalic. atrsurnatic. AFSF. No masses. lesions. tenderness or Iymphadenopathy. Trach in place with HME. old/i Eyes: Pupils equal. round. reactive to light and conjunctiva clear. without lcterus or injection. Extraccular muscles Intact. with symmetrical movement bilaterally. Ears: External ears and external auditory canals normal Nose: Bilateral narcs patent. nasal septum midiine. +nasai congestion. no arythema. Moist mucous membranes - LungaICheat: Good air entry bilaterally. some coarse breath sounds. no wheezing. Mild subcostal retractions. Heart: St and 32 normal. Normal rats and regular No murmur. no rub. no gallop. capillary re?ll