Private Duty Nursing Services

Updated: April 2026

Purpose

Private Duty Nursing (PDN) services are for members who require more individual or continuous care than is available from a visiting nurse. The services must be provided by a registered nurse (RN) or licensed practical nurse (LPN) in a member's home or other approved setting under the direction of the member's physician.

PDN services support, but do not replace skilled care provided to a member by parents, family, and other responsible caregivers. Commitment by the family and community is necessary to meet the member’s needs and to ensure the member can remain safely at home.

Applicability

Eligible Providers

To receive payment from ND Medicaid, the eligible servicing and billing providers must be enrolled with ND Medicaid on the date of service, and their National Provider Identifiers (NPIs) must be active in their Medicaid enrollment records. Servicing providers acting as a locum tenens provider must be enrolled with ND Medicaid, and services they provide must be billed with their NPI. Please refer to provider enrollment for additional details on enrollment eligibility and supporting documentation requirements.

ND Medicaid covers services provided by PDN agencies that are licensed and enrolled with ND Medicaid. The services must be provided by an RN or an LPN in a member's home or other approved setting under the direction of the member's physician. 

Eligible Members

Providers are responsible for verifying a member’s eligibility before providing services. Eligibility can be verified using the ND Medicaid MMIS Portal or through the Automated Voice Response System by dialing 1.877.328.7098.

To qualify for coverage of PDN services, a member must meet the criteria listed below:

• The member must require medically necessary skilled PDN care. 
• A physician, nurse practitioner, clinical nurse specialist, or physician assistant must certify that the member requires PDN care in the home.
• Services must be medically necessary and considered the most appropriate setting consistent with meeting the member’s medical needs. 
• Services must be provided at the member’s place of residence, or other setting as prior authorized. The member’s residence must not be an intermediate care facility for individual with intellectual disabilities; and institution for individuals with a mental disease, hospital, or nursing facility.
• The member must identify at least one trained informal caregiver who can provide direct care to the member during planned and unplanned absences of PDN staff. Informal caregivers should routinely provide hands-on care to maintain their general care skills, and ensure they are competent in providing backup care when the PDN staff is unavailable.

Refer to the Member Eligibility Manual for additional information regarding eligibility including information regarding limited coverage categories. 

Covered Services and Limits

General Provider Policies

The General Provider Policies details basic coverage requirements for all services. Basic coverage requirements include:

• The provider must be enrolled in ND Medicaid;
• Services must be medically necessary;
• The member must be eligible on the date of service; and
• If applicable, the service has an approved service authorization. 

The Procedure Code Look-up Tool  can be used to identify if a procedure code is covered by ND Medicaid along with code specific details such as ORP requirements, Service Authorization requirements, and current rates. 

ND Medicaid covers PDN services that meet the following criteria: 

• Medically necessary;
• Authorized under a ND Medicaid service authorization (SA);
• Provided in the member's residence, or other approved setting, as authorized. The member’s residence must not be an intermediate care facility for individuals with intellectual disabilities; and institution for individuals with a mental disease, hospital, or nursing facility; 
• Provided to a member who requires more patient care than could be provided by a home health agency or professional day care when a condition or illness would result in institutionalization if not cared for at home;
• Parent, guardian, or primary caregiver is committed to and capable of performing skills necessary to ensure quality of care and a safe environment for the periods of time when PDN services are not provided;
• Member’s physician orders the PDN services;
• PDN agency must complete an evaluation and create a Plan of Care;
• Plan of Care signed by the ordering physician;
• Private Duty Nursing Service Authorization (SFN 224) and the Home Health Certification and Plan of Care, along with medical records to support the requested care are submitted for determination of covered PDN hours.
• Protective equipment, including personal protective equipment, shall be provided by the PDN agency at no cost to the employee or member.

PDN hours are determined by a comprehensive review of medical information and other required documentation submitted by the PDN agency. This can include primary medical diagnosis(es), physician’s orders, nursing interventions, dependence on life-sustaining medical technology, verification of employment, and nursing hours provided in the school, if applicable, to determine the number of eligible hours. The hours approved are based on the needs of the member and caregiver availability, not the needs of other individuals residing in the home. 

Limits

ND Medicaid PDN coverage is limited to: 

• Hours determined medically necessary;
• Hours requested by the ordering physician
• Hours that guardian(s) work and travel to work; or 
• Hours that parent(s) attend school and travel to school; or
• Additional hours for sleep may be allocated for up to 8 hours per 24-hour period when the member's condition and care plan requires intensive nursing interventions and monitoring. Examples of intensive nursing interventions and monitoring include trach and vent dependency with frequent suctioning or the need for ongoing oxygen monitoring, frequent seizure activity with interventions or other prescribed medically necessary service(s) required with a frequency of every 2 hours or more.

PDN hours are not 24 hours/7days a week and cannot be used for respite.  Developmental Disability and HCBS waiver participants may request respite services or Developmental Disability services from the Department of Health and Human Services (DHHS).

Parent/Guardian(s) are responsible for notifying the PDN agency of their work/school schedule. The PDN agency must document and provide this information in the Plan of Care and SA request in addition to submitting a signed North Dakota

Medicaid Private Duty Nursing Parent/Guardian Attestation (SFN 197). Parent/Guardian(s) and the PDN agency are responsible for using their hours in accordance with North Dakota Medicaid policy. 

PDN services are limited to one nurse in a member's residence or other approved setting at a time per member. Medicaid will only cover more than one nurse in the member's residence or other approved setting for multiple members in the same residence or approved setting if all members require intensive nursing interventions and monitoring. These interventions and monitoring include trach and vent dependency with frequent suctioning or the need for oxygen monitoring, frequent seizure activity with interventions, or other prescribed medically necessary nursing interventions required with a frequency of every 2 hours or more.

Service Authorization Requirements

A service authorization is required for all PDN services. ND Medicaid contracts with Acentra, a Quality Improvement Organization, to review PDN service authorizations. Acentra uses a nationally recognized clinical support tool, with evidence-based criteria to determine if a member meets a certain level of care or services based on the member’s needs and determine the number of approved medically necessary PDN hours (e.g., InterQual). Please note that hours approved may be less than or equal to what the physician has ordered and is based upon clinical documentation supplied and the evidence-based criteria.

The service authorization requests are submitted to Acentra through the Atrezzo portal. More information can be found at https://nddhs.acentra.com/.

PDN agencies must submit the following information with their SA request: 

• Private Duty Nursing Service Authorization (SFN 224);
• North Dakota Medicaid Private Duty Nursing Parent/Guardian Attestation (SFN 197);
• Medical records; and 
• Home Health Certification and Plan of Care signed by the practitioner.

PDN authorizations are limited to a maximum of 60 days per authorization. If a reauthorization is being requested, an updated plan of care, indicating the need for continued PDN services, signed by the attending physician and a current SFN 197 must be submitted. It must be received by ND Medicaid prior to the service being done and before the next 60-day period. If the service authorization is not received prior to the 60-day time period, the PDN hours will be denied. 

Requests not meeting these criteria may be returned, denied, or rejected as incomplete. Providers may include letters or narrative with their request for service authorization; however, information supplied in a letter or narrative does not supplant the need for documentation supporting medical necessity in the medical record. 

Noncovered Services

General Non-Covered Services

The Noncovered Services Policy contains a general list of services that are not covered by North Dakota Medicaid.

Noncovered PDN services include:

• Custodial or sitter care to ensure compliance with treatment;
• Respite care outside of what is allowed for the guardian(s) as described in the Covered Services and Limits section of this policy;
• Behavioral or eating disorders;
• Hours while the child is at school or in other supervised settings; and
• Services provided in an intermediate care facility for individuals with intellectual disabilities or an institution for individuals with mental disease or nursing facility.

Documentation Requirements

General Requirements

Providers must keep legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid. Records must be retained for at least 7 years after the last date the claim was paid or denied. Providers must follow the documentation requirements in the Provider Requirements Policy. 

The PDN agency must keep on file copies of all documents submitted to ND Medicaid.  Approved SAs are dependent on the member's eligibility during the approved SA period.

Reimbursement Methodology and Claim Instructions

Timely Filing

ND Medicaid must receive an original Medicaid primary claim within one hundred eighty (180) days from the date of service. The time limit may be waived or extended by ND Medicaid in certain circumstances. The Timely Filing Policy contains additional information.

Third-Party Liability

Medicaid members may have one or more additional source of coverage for health services. ND Medicaid is generally the payer of last resort. Providers must pursue the availability of third-party payment sources. The Third Party Liability Policy contains additional information.

Client Share (Recipient Liability)

Client share (recipient liability) is the monthly amount a member must pay toward the cost of medical services before the Medicaid program will pay for services received. The Client Share Policy contains additional information. 

Reimbursement

A claim for services must be submitted at the provider’s usual and customary charge. Payment for services is limited to the lesser of the provider’s usual and customary charge or the ND Medicaid calculated reimbursement. 

ND Medicaid covers the following services:

• S9124 Skilled Nursing (LPN)
• S9123 Skilled Nursing (RN)

Claim Form

PDN Services must be billed using the CMS 1500 claim form or 837p. Detailed claim instructions are available on the North Dakota Medicaid Provider Guidelines, Policies & Manual webpage.

Definitions

Plan of Care – the plan developed by the PDN agency in response to the attending physician or other licensed practitioner's written orders to the agency prescribing the needed services and the duration of those services. 

Member – the individual who is eligible for Medicaid.

References

• North Dakota Administrative Code
• North Dakota Century Code
• Code of Federal Regulations

Frequently Asked Questions

Question (Q): How does a member get services?
Answer (A): A practitioner must write the order. The member or guardian should contact a PDN agency to obtain an evaluation and plan of care. Once a plan of care is written, the practitioner must sign the plan of care. That plan and medical documentation is then sent by the PDN agency to NDMA/Acentra to request a service authorization determination. A PDN agency can provide services according to the schedule established.  

Q: Can a child receive PDN services while in school?
A: No, the child cannot receive PDN services while in school. School districts may provide nursing services, based upon medical necessity, during the school day.

Q: Does the RN/LPN need to be employed by a Medicaid enrolled PDN agency?
A: Yes, RNs and LPNs must be employed by a Medicaid enrolled PDN agency.

Contact

Medical Services
600 East Boulevard Ave 
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov

Policy Updates

April 2026

• ADA updates made throughout document. 
• Purpose
  • Added clarifications related to PDN.
• Applicability
  • Added information for eligible providers and members.
• Documentation Requirements
  • Added clarifications throughout section.