MedicaidPrior AuthHigh impact
Pediatric Day Health Care (PDHC) - MEDICAID - LOUISIANA (New)
Humana·LA · Pediatrics, Critical Care·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This is a new Humana Louisiana Medicaid policy (effective 01/01/2023, most recently approved 01/20/2025) establishing coverage and prior authorization requirements for Pediatric Day Health Care (PDHC) services for medically complex children ages birth to 21. The policy mandates prior authorization, requires comprehensive documentation including physician orders and plans of care, and limits certification periods to 90 days with required face-to-face physician evaluations every 90 days (extendable to 180 days in exceptional circumstances).
Action Required
By 02/20/2025: Billing team must implement prior authorization workflow for all PDHC service requests from Louisiana Medicaid (Humana Healthy Horizons) members. (1) Update billing system to flag all PDHC claims as requiring prior authorization before claim submission. (2) Create or update prior authorization submission checklist to include: Prior Auth form, physician's most recent note documenting medical necessity, physician's order, Prior Authorization checklist indicating skilled nursing care requirements, and plan of care. (3) Implement 90-day recertification tracking system to ensure claims are not processed beyond certified periods without updated prior authorization documentation. (4) Brief providers and front desk staff that all PDHC requests require documented physician orders, signed parent/guardian consent, and face-to-face physician evaluation every 90 days. (5) Train billing staff to reject incomplete submissions and provide clear feedback on missing documentation. Failure to obtain prior authorization will result in claim denials. Update internal documentation templates to reflect these requirements.