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4.3.2.2 Exceptions to Limited Status
The provider is not required to provide some services. Limited clients may go to any provider for the following services or items:
• Ambulance services
•Anesthesia
•Annual well-woman checkup
•Assistant surgery
•Case management services
•Chiropractic services
•Counseling services provided by a chemical dependency treatment facility
•Eye exams for refractive errors
•Eyeglasses
•Family planning services (regardless of place of service [POS])
•Genetic services
•Hearing aids
•Home health services
•Laboratory services (including interpretations)
•Licensed clinical social worker (LCSW) services
•Licensed professional counselor (LPC) services
•Mental health rehabilitation services
•Mental retardation diagnostic assessment (MRDA) performed by an MRDA provider
•Nursing facility services
•Primary home care
•Psychiatric services
•Radiology services (including interpretations)
•School Health and Related Services (SHARS)
•THSteps-CCP
•THSteps medical and dental services
For referrals or questions, contact:
HHSC
Office of Inspector General
Limited Program - MC 1323
PO Box 85200
Austin, TX 78708
1-800-436-6184
If an emergency medical condition occurs, the limited restriction does not apply. The term emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain), such that the absence of immediate medical attention could reasonably be expected to result in:
•Placing the patient's health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
•Serious impairment to bodily functions.
•Serious dysfunction of any bodily organ or part.
Important: A provider who sends in an appeal because a claim was denied with explanation of benefits (EOB) 00066 must include the performing provider identifier, not just a name or group provider identifier. Appeals without a performing provider identifier are denied. The National Provider Identifier (NPI) of the designated provider must be entered in the appropriate paper or equivalent electronic field for nonemergency inpatient and outpatient claims to be considered for reimbursement.
Note: Only when the designated provider or designated provider representative has given permission for the client to receive nonemergency inpatient and/or outpatient services, including those provided in an emergency room, can the facility use the designated provider's NPI for billing.
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