MedicaidPrior AuthMedium impact
Pediatric Day Health Care - MEDICAID - LOUISIANA (Revised)
Humana·LA · Pediatrics, Physical Therapy, Occupational Therapy +1 more·Medicaid
Effective date
Jul 20, 2026
We identified it
Jul 16, 2026
Summary
This is a revised Pediatric Day Health Care (PDHC) policy for Louisiana Medicaid that clarifies coverage criteria, prior authorization requirements, and plan of care documentation standards for complex medical children aged birth to 21. The policy reaffirms that ALL PDHC services require prior authorization (up to 7 days/week, 12 hours/day, certified for max 90 days) and specifies that face-to-face physician evaluations must occur every 90 days for renewal, with an option to extend to 180 days in exceptional circumstances. Key exclusions include respite care, child care, education services, and infant formula.
Action Required
Before July 20, 2026: Billing team must update prior authorization workflows to enforce the revised PDHC requirements for Louisiana Medicaid members. Specifically: (1) Ensure all PDHC service requests trigger mandatory prior auth requests requiring physician order, completed prior auth checklist, and Plan of Care signed by parent/guardian, facility representative, and prescribing physician; (2) Configure billing system to recognize HCPCS codes T1025 (per diem), T1026 (per hour), and T2002 (transportation per diem) as PDHC billable codes; (3) Set up renewal tracking to require face-to-face physician evaluation documentation every 90 days (or 180 days if exceptional circumstances noted) with updated POC; (4) Implement claims rejection rules for excluded services (respite, child care, education, infant formula, medical equipment, parenteral/enteral nutrition) when billed under PDHC per diem; (5) Update provider and parent education materials to clarify that PDHC does NOT provide respite care. Providers ordering PDHC must document why services cannot be provided in school or other integrated community settings. Failure to obtain proper prior authorization will result in claim denials. Front desk staff should flag PDHC requests for authorization coordinators immediately upon receipt.