Private Duty Nursing and Pediatric Long-Term Home Health Prior Authorization Requirements

Effective Nov. 1, 2021

The Department of Health Care Policy & Financing (HCPF) is phasing out administrative approvals beginning November 1, 2021 for private duty nursing (PDN) and pediatric long-term home health (PLTHH) benefits. Prior authorization requests (PARs) for PDN and PLTHH benefits have been administratively approved through October 31, 2021 to accommodate HCPF’s work to revise the denial notices and complete system changes. Beginning November 1, 2021, HCPF will begin instituting PARs for these services.

HCPF has identified expectations for Regional Accountable Entities (RAEs), Managed Care Organizations (MCOs), Case Management Agencies (CMAs), and the Utilization Management (UM) regarding care coordination and case management for Health First Colorado (Colorado’s Medicaid Program) members who received administrative approvals for private duty nursing and pediatric long-term home health benefits. HCPF and CCHA anticipate most members currently receiving these services will not be impacted but understand coordinated, tailored support for individuals and families will be needed.

How CCHA Will Support This Effort

As part of our role to support Health Frist Colorado members, CCHA will be work with CMAs and HCPF to provide the following supports to members and providers during this implementation, and ongoing.

  • Conduct outreach to members that receive a denial for PDN or pediatric LTHH services to offer care coordination support.
  • Coordinate support for members with CMA and home health providers.
  • Support members in their desire to appeal a decision.
  • Work closely with providers on providing care coordination support for members who receive a denial of services.
  • Discus the process and roles at quarterly single entry point (SEP) and community centered boards (CCBs) collaboration meetings.

If providers have questions regarding this change in prior authorization requirements, including documentation necessary, please see HCPF’s Private Duty Nursing and Pediatric Long-Term Home Health Services Pre-Approval Project page or contract Providers@cchacares.com.

If members have questions, please contact CCHA Member Support Services.

If you need the information on this page in another format, please contact CCHA Member Support Services.

The information will be provided in paper form free of charge within 5 business days.

We can connect you to language services or help you find a provider with ADA accommodations.

If you are having a medical or mental health emergency, call 911 or go to your nearest hospital-based ER.

If you are having a mental health or substance use crisis, call Colorado Crisis Services at 1-844-493-8255.