Sheet 1: Instructions

	
	

		
Ad Hoc PDN Report Instructions
	
	

		


	
	

		
This is an Ad hoc report generated by the Agency.
	
	

		
Do not make any entries other than those specified below. Do not alter template or formulas.
	
	

		


	
	

		


	
	

		
1. The request should be limited to members receiving the PDN rate cell, with the time period above pertaining to the service month. Only members that were in the same plan for the service month and payment month should be reported.
	
	

		
2. Roll-up the data by member/provider.
If a member has multiple lines for the same provider, roll the data up into one line showing the total number of hours for that member and provider for the time period requested.
	
	

		
3. Roll-up data by member (optional).
If a member has multiple providers, the plan may roll the data up into one line for the member and may cap the authorized hours to 24 per day.
	
	

		


	
	

		


	
	

		
Managed Care Plan Information
	
	

		


	
	

		
Health Plan Name: Enter the complete health plan name.
	
	

		


	
	

		
Benefit Type: Enter the health plan's benefit type. ("LTC" or "MMA")
	
	

		


	
	

		
Health Plan 7-Digit Medicaid ID: Enter the seven (7)-digit health plan Medicaid identification number.
	
	

		


	
	

		
Reporting Period: Enter the quarterly reporting periodin this format: MM/DD/YYYY - MM/DD/YYYY.
	
	

		


	
	

		
Report Submission Date: Enter the date the health plan submitted the report in the following format: MM/DD/YYYY.
	
	

		


	
	

		
Report Submitted By: Enter the first name and last name (ONLY) of the health plan's contact individual for this report. Exclude titles, "Sr", "Jr", "2nd", etc.
	
	

		


	
	

		
Instructions Option 3 Was Used? (Yes or No): Enter "Yes" if the plan rolled the data into one line for the member. Enter "No" if otherwise.
	
	

		


	
	

		


	
	

		
PDN Report Tab:
	
	

		


	
	

		
Enrollee's Full Name: Enter the enrollee's last name, followed by the enrollee's first name. The request should be limited to members receiving the PDN rate cell, with the time period above pertaining to the service month.  Only members that were in the same plan for the service month and payment month should be reported.
	
	

		


	
	

		
Enrollee's Medicaid ID: Enter the enrollee's ten (10)-digit Medicaid identification number.
	
	

		


	
	

		
Date of Birth: Enter the enrollee's date of birth in the following format: MM/DD/YYYY. Report only recipients under the age of twenty-one (21).
	
	

		


	
	

		
Current Age in Years: Enter the enrollee's current age in years. For example, if the enrollee is 6 months old, insert "0" for the age in years.
	
	

		


	
	

		
Region: Enter the enrollee's region.
	
	

		


	
	

		
County of Residence: Enter the enrollee's county of residence.
	
	

		


	
	

		
Total Number of PDN Hours Authorized (10/1/2019 - 03/31/2020): Enter the total number of private duty nursing (PDN) hours authorized for the enrollee -- utilization management system.
	
	

		


	
	

		
Total Number of PDN Hours Provided (10/1/2019 - 03/31/2020): Enter the total number of PDN hours provided for the enrollee -- claims data.
	
	

		


	
	

		
Average Percentage of PDN Hours Provided: The column auto-calculates the "Total Number of PDN Hours Authorized (Numerator)" over the "Total Number of PDN Hours Provided (Denominator)". DO NOT ALTER THE FORMULA.
	
	

		


	
	

		
Home Health Agency Name: Enter the name of the Home Health Agency providing services for the enrollee (optional).
	
	

		


	
	

		
Comments: Enter any additional information regarding the enrollee.