How to Build a Prior Authorization-Ready Private Duty Nursing Referral

When a child or adult needs Private Duty Nursing (PDN), the referral often reaches the health plan at a difficult moment: a hospital discharge may be approaching, the family may be managing complex care at home, and several organizations may be requesting different documents.

A diagnosis or physician order alone may not give a commercial health plan enough information to determine whether PDN is a covered benefit, whether the requested care meets the plan’s clinical criteria, or how many hours may be authorized. A coordinated referral package can make the request easier to evaluate and reduce avoidable delays caused by missing or inconsistent information.

Because benefits and requirements vary by plan, families and referral professionals should confirm the patient’s specific coverage and follow the plan’s current submission instructions. The following framework can help organize that work.

Start With the Member’s Actual Benefit Plan

Commercial insurance is not one uniform benefit. Two members carrying cards from the same insurance company may have different coverage, exclusions, authorization rules, provider networks, and appeal procedures.

Before assembling the clinical packet, confirm:

The patient’s exact plan and member identification information
Whether the plan is fully insured or employer self-funded
Whether PDN or continuous skilled nursing is included, excluded, or limited
Whether prior authorization or precertification is required
Whether the request must be submitted by the ordering clinician, nursing agency, facility, or another party
Which forms, portal, fax number, or electronic process the plan requires
Whether separate network approval is needed if no participating agency can accept the case
The applicable appeal and expedited-review procedures

Request the current benefit booklet, certificate of coverage, Summary Plan Description, or other governing plan document. A customer-service summary can be helpful, but the written plan terms generally provide the more complete description of coverage and claims procedures.

Use a Clear, Current Clinical Order

The clinical order should identify what is being requested, not merely state “home nursing.”

Depending on the patient and payer, it may need to address:

Private Duty Nursing or continuous skilled nursing
RN, LPN, or either level of nursing
Requested hours per day and days per week
Anticipated start date
Diagnoses and relevant clinical conditions
Skilled treatments, monitoring, and interventions
The duration of the requested authorization period
Parameters for contacting the physician or escalating care

The order, plan of care, nursing assessment, and requested schedule should be consistent. If one document requests 12 hours per day while another describes an eight-hour need, the health plan may pause its review for clarification.

Provide a Signed Plan of Care

A complete plan of care helps connect the physician’s order to the patient’s daily nursing needs. It should reflect the current clinical picture, not an outdated hospitalization or an earlier level of care.

For example, UnitedHealthcare’s current Commercial and Individual Exchange PDN policy, effective August 1, 2026, states that requests should be documented using a CMS-485 plan of care signed by a physician or an authorized advanced practitioner, subject to applicable law. Other health plans may use different forms or require additional documentation, so the plan’s current instructions should always be checked.

A useful plan of care may include:

Diagnoses and relevant medical history
Medication names, routes, schedules, and monitoring requirements
Respiratory treatments and emergency protocols
Tracheostomy, ventilator, oxygen, suctioning, or airway-management needs
Enteral or parenteral nutrition and related monitoring
Seizure precautions and rescue-medication instructions
Central-line, catheter, wound, or other skilled procedures
Required assessments, documentation, and physician-notification parameters
Patient-specific safety risks and emergency actions
Family or caregiver teaching needs

Explain Why the Care Requires a Licensed Nurse

Commercial plans often distinguish skilled nursing from custodial or personal care. The referral should therefore explain why the requested tasks require the clinical training, judgment, assessment, or intervention of an RN or LPN.

Rather than relying only on a list of diagnoses, describe:

What the nurse must assess
How often an intervention or reassessment may be needed
What clinical changes the nurse must recognize
What action the nurse must take if the patient’s status changes
Why an unlicensed caregiver could not safely perform or supervise the care alone
The foreseeable consequences of a delayed or incorrect response

For example, stating that a patient has a tracheostomy identifies a condition. Explaining the need for airway assessment, suctioning, recognition of respiratory deterioration, equipment checks, and emergency response shows the skilled nursing work associated with that condition.

Create a 24-Hour Care and Treatment Schedule

A daily care grid can help the reviewer understand how the requested nursing hours were calculated.

The schedule should show:

Timed medications and treatments
Continuous or frequent monitoring
Feeding and hydration schedules
Respiratory care
Therapy, school, work, sleep, and transportation times
Periods of higher clinical risk
Available caregiver coverage
The specific blocks of time for which licensed nursing is requested

The goal is not simply to show that the patient has substantial needs. It is to connect the requested hours to the frequency, timing, complexity, and risk of the skilled services.

Document Recent Clinical Events and Current Stability

Include records that demonstrate the patient’s present needs, such as:

Recent hospital discharge summary
Current history and physical
Specialist notes
Nursing assessments
Medication administration record
Treatment or respiratory logs
Relevant emergency-department visits or hospitalizations
Changes in equipment, medications, or treatments
Recent complications or significant clinical events
Previous authorization information, if relevant

“Stable” does not necessarily mean that skilled nursing is unnecessary. In some cases, stability is maintained because treatments, monitoring, and timely nursing interventions are consistently provided. The documentation should explain that relationship when it applies.

Describe Caregiver Availability Accurately

Health plans may request information about family or caregiver availability, training, work schedules, sleep needs, and ability to participate in care. This information should be accurate and specific.

A caregiver’s ability to learn certain tasks does not automatically resolve whether PDN is medically necessary under the plan. At the same time, the referral should not assume that every hour without a nurse will be covered. Explain what the family can reasonably and safely provide, what care requires licensed nursing, and where the proposed schedule leaves unresolved clinical risk.

Keep the discussion factual. Avoid presenting family preference alone as the clinical basis for nursing hours.

Separate Four Different Decisions

Families and referral teams should recognize that several approvals may be involved:

Benefit verification: Does the member’s plan include PDN?
Medical-necessity authorization: Does the submitted record satisfy the plan’s clinical criteria, and for how many hours?
Network authorization: May a particular agency provide the service, including through a network-gap exception if necessary?
Reimbursement arrangement: Are the billing codes, rates, effective dates, and payment terms established?

Approval at one level does not necessarily complete the others. For example, authorization of PDN hours does not automatically establish an out-of-network payment agreement.

Submit One Indexed, Trackable Packet

Where possible, submit a single organized packet with a cover sheet or index. Label every attachment and avoid sending conflicting versions of the same document.

The submission record should include:

Patient and member identifiers
Requested service, nursing level, hours, and dates
Ordering clinician’s information
Nursing agency information, if selected
List of attached clinical records
Submission date and method
Portal confirmation, fax confirmation, or reference number
Name and department of any representative contacted
Deadline or expected decision date
Any request for expedited review and the clinical reason

If the plan requests additional information, respond through the required channel and keep proof of the response. Ask whether the review clock is paused and whether any other document remains outstanding.

Prepare for an Urgent Review or Appeal

If ordinary review could seriously jeopardize the patient’s health, delay a necessary discharge, or interrupt ongoing care, ask the plan whether expedited review is available and have the ordering clinician explain the urgency.

If the request is denied, reduced, or not approved as submitted, obtain the decision in writing. Review:

The exact reason for the decision
The plan provision or clinical criterion applied
Any document the plan says was missing
The approved service level or hours, if partially approved
Internal appeal steps and deadlines
Expedited appeal rights
External-review rights, when applicable

New Jersey’s utilization-management appeal system applies to certain fully insured health benefits plans issued or delivered in New Jersey, but it does not apply to self-funded employer plans. Self-funded plans generally follow the procedures in their plan documents and applicable federal requirements. The insurance card alone may not make the funding arrangement clear, so confirm it with the employer or plan administrator.

How Carnegie Healthcare Can Help

Carnegie Healthcare Corporation provides Private Duty Nursing for medically complex children and adults in New Jersey.

Our team works with families, physicians, hospital discharge planners, case managers, and commercial health plans to review referrals, identify missing information, organize clinical documentation, verify benefits, pursue required authorizations, and evaluate available network or single-case pathways.

Coverage, authorized hours, reimbursement, and nursing availability depend on the patient’s plan, clinical circumstances, and staffing needs. Carnegie Healthcare cannot guarantee approval or payment, but we can help the parties understand what information is needed to evaluate a referral.

To discuss a potential Private Duty Nursing referral, call (609) 530-1800 or submit a request through our contact page.

Helpful Resources

This article provides general educational information and is not medical, legal, insurance, or benefits advice. Coverage, medical-necessity criteria, authorization requirements, appeal rights, network rules, and cost sharing vary by health plan and individual circumstances. Families and providers should consult the member’s current plan documents, treating clinicians, health plan, and appropriate professional advisers.