Effective November 1, 2025: Private Duty Nursing Modifiers

Date: 10/02/25

Effective November 1, 2025, Private Duty Nursing (PDN) Modifiers must be Prior Authorized for Medicaid (STAR Kids, STAR Health, STAR) and CHIP members.

What Is New: PDN providers that request prior authorization for PDN specialized care (procedure code T1000 with modifier UA), and specialized nursing care provided by a Registered Nurse (procedure code T1000 with modifier TD Registered Nurse (RN) must submit all clinical documentation required for PDN services as well as a physician’s order that include the clinical indications that justify PDN services with UA or TD modifiers. Prior authorization requests that do not specify modifier TD (RN) will be reviewed based on modifier TE (Licensed Vocational Nurse).

• PDN specialized care (T1000 with UA modifier) is exclusive to members who are dependent on invasive mechanical ventilation or have a functioning tracheostomy that requires suctioning or specialized nursing care. Members receiving non-invasive ventilation do not qualify for the UA modifier. Non-invasive ventilation methods include ventilator used as a Respiratory Assistance Device (RAD), Continuous Positive Airway Pressure (CPAP), Auto-Titrating Positive Airway Pressure (APAP), Bilevel Positive Airway Pressure (BPAP or BiPAP), and Adaptive Servo-Ventilation (ASV).
• Modifier TD (RN) for members with complex health care needs requires independent nursing care with substantial specialized judgment and skill.
• Modifier TE (LVN) should be used when a member requires care involving nursing judgment and skill but within a more limited framework than an RN. 
• Procedure code T1000 AND all appropriate modifiers (UA, TD, TE) must be included on the Prior Authorization Request and include a brief description of the services requested:
  • Medicaid:  CCP Prior Authorization Request Form (PDF)
  • CHIP: Signed and dated practitioner’s order or signed Plan of Care (POC)

Medical necessity must also be included in the Home Health POC, the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers forms. The criteria for medical necessity is included in the Effective November 1, 2025: Clinical Policies – Private Duty Nursing (TX.CP.MP.520 Private Duty Nursing [Medicaid] and TX.CP.MP.521 Private Duty Nursing [CHIP])

• Documentation for T1000 AND modifier UA must include:
  • The primary care provider must include the settings or modes for required equipment (e.g., ventilator, oxygen) in the physician-recommended POC.

When This Applies: Prior Authorization Requests submitted on or after November 1, 2025

Prior Authorization Requests:

• Online:
  • Availity Essentials Portal
  • Superior's Secure Provider Portal
• Phone:
  • 1-800-218-7508
• Fax:
  • 1-800-690-7030

Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided. Below are the Current Procedural Terminology (CPT) codes and modifiers included in this change to the prior authorization requirements.

                  

Procedure Code	Applicable Products	Criteria
T1000 - Private duty / independent nursing service(s) - licensed, up to 15 minutes	Medicaid (STAR, STAR Health, STAR Kids), CHIP	Updated Clinical Policies: Effective November 1, 2025: Clinical Policies – Private Duty Nursing Medicaid: TX.CP.MP.520 Private Duty Nursing - Medicaid CHIP: TX.CP.MP.521 Private Duty Nursing – CHIP
Modifiers for T1000:       UA - Specialized services       TD - Registered Nurse       TE – Licensed Vocational Nurse

To review prior authorization requirements, please visit Superior’s Prior Authorization webpage.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.