Newsletter Vol. 4, No. 15

Immediately: Billing team must implement the following workflow for all private duty nursing claims exceeding 16 hours per day: (1) Providers must contact the recipient's Case Manager before billing; (2) Case Manager obtains approval from OHCP and Medicaid District Office (MDO); (3) Provider contacts OHCP to receive prior authorization number on Form FD; (4) Billing team must enter the prior authorization number in Item B of the NJ claim form before submission; (5) Each date of service must be entered on a separate line in Item A of the NJ claim form (do not span dates); (6) Enter hours of service in Item F of the NJ claim form (each hour = one unit; maximum 16 units per day when not prior authorized). Update billing software to flag claims with more than 16 hours of private duty nursing per day and require prior authorization documentation. Train all billing staff on the new approval process. Failure to obtain prior authorization will result in claim denials with Edit Code 'Excessive Private Duty Nursing Hours.'