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4.3.2 Client Limited Program
Texas Medicaid fee-for-service (nonmanaged care) clients can be limited to a primary care provider and/or a primary care pharmacy. Medicaid managed care clients can be limited to a primary care pharmacy.
The client is assigned to a designated provider for access to medical benefits and services when one of the following conditions exists:
• The client received duplicative, excessive, contraindicated, or conflicting health-care services, including drugs.
•A review indicates abuse, misuse, or fraudulent actions related to Medicaid benefits and services.
After analysis through the neural network component of the Medicaid Fraud and Abuse Detection System (MFADS), qualified medical personnel validate the initial identification and determine candidates for limited status. The validation process includes consideration of medical necessity. For the limited status designation, medical necessity is defined as the need for medical services as to the amount and frequency established by accepted standards of medical practice for the preservation of health, life, and the prevention of more impairments.
Except for specialist consultations, services rendered to a client by more than one provider for the same or similar condition during the same time frame may not be considered medically necessary. For questions about pharmacy services for clients limited to a primary care pharmacy, contact the Limited Program Hotline at
1-800-436-6184, option 4.
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