2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Home HealthPresbyterian Medicaid members are notrequired to be homebound to be eligible forhome care servicesPresbyterian Medicaid Early and PeriodicScreening, Diagnosis, and Treatment ServicesMedically Fragile Home and Community-BasedServicesThese services are case managed through theUniversity of New Mexico (UNM) CaseManagement Program for children less than 21years of age. Referrals to this program are directedto UNM case managers at 505-272-2910. The casemanager with the interdisciplinary team evaluatesthe child and determines the level of care required.Services include hourly private duty nursing and/orhourly home health aide care. PHHSN priorauthorizes care as directed by UNM casemanagers’ assessment and budget.Personal Care ServicesThe EPSDT, personal care services admissioncriteria are as follows:Recipient must be under 21 years of ageRecipient must have a need for assistancewith at least two physical requirements suchas eating, bathing, dressing or toileting acts,appropriate to his or her agePersonal care services must be medicallynecessary and prescribed by their physicianand included in the plan of treatmentThe need for personal care services isevaluated based upon formal and informalsupport, availability of family members, othercommunity resources, and/or friends who canassist in providing such carePersonal care must have the consent ofrecipient’s parents or guardians if the recipientis under the age of 18 years, and therecipient’s consent if over the age of 18Personal care services that are medicallynecessary are furnished in the recipient’shome or outside the home when medicallynecessary and are not available throughtraditional programsThese services cannot be provided to peoplewho are in a hospital, nursing facility,intermediate care facility, or facility for thementally retarded or an institution for mentaldiseasePersonal care services that are medicallynecessary for attending school are furnishedin partnership with the recipient’s school as analternative to participation in a homeboundprogram, with the services fostering the child’sindependencePersonal care services are furnished basedon approval by the designated utilizationreview agentServices must be provided by a personal careattendant (PCA) who is trained and demonstratescompetency to provide assistance with personalcare. The PCA must be employed by the agencyand work under the supervision of a registerednurse (RN). The supervising RN must have oneyear direct patient care experience and must makehome visits every 62 days or as often as needed toassess the recipient’s progress and the PCA’s11-42014 Practitioner and Provider Manual - Ver. 3