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7.7.12.1 Self-Referred Services
PCCM clients may select any Medicaid-enrolled provider to access the following services without a referral:
• Emergency Services. In case of a medical emergency, clients may seek emergency medical services from the nearest facility. To ensure continuity of care, the emergency facility is asked to contact the client's primary care provider within 24 hours or the next business day after providing services. Primary care providers or a primary care provider's designee must be available to respond to an ER call promptly. If the emergency visit results in an admission, the facility also must notify PCCM to receive authorization prior to claims submission.
Refer to: "PCCM Inpatient Authorization Process" .
•OB/GYN Services. PCCM clients may select a PCCM-contracted OB/GYN as their primary care provider. As a primary care provider, the OB/GYN is responsible for providing or arranging all medically necessary services. PCCM clients may also seek direct services of any Medicaid-enrolled OB/GYN, family practitioner, or internal medicine provider who is not their primary care provider for the following services:
•One well-woman examination per year
•Care related to pregnancy
•Care for all active gynecological conditions
•Diagnosis, treatment, and referral to a Medicaid-enrolled specialist for any disease or condition within the scope of the designated professional practice of a licensed obstetrician or gynecologist, including treatment of medical conditions concerning the breasts
A referral from the PCCM client's primary care provider is not required as long as the provider rendering services is a Medicaid-enrolled OB/GYN, family practitioner, or internal medicine provider.
•Family Planning Services. Family planning services include preventive health, medical counseling, and educational services that assist individuals in planning and/or preventing pregnancy and achieving optimal reproductive and general health. Primary care providers are encouraged to provide these services if requested by a client. Clients are not required to obtain family planning services through their primary care provider. Family planning is a service that does not require a primary care provider referral. Clients may go to a DSHS Family Planning state-contracted Medicaid facility for family planning services. Inpatient services must be delivered in a PCCM-contracted hospital/facility.
•THSteps. PCCM clients may select any THSteps-enrolled Texas Medicaid provider to perform THSteps services. If a THSteps medical checkup is performed by a provider who is not the client's primary care provider, this information should be forwarded to the client's primary care provider so that the client's medical record can be updated.
Refer to: "Texas Health Steps (THSteps)" .
•Vision Services. Clients do not need a referral to access necessary covered vision services. Covered vision services are:
•One eye exam each state fiscal year (September 1 through August 31) for clients 20 years of age or younger unless there is a diopter change of 0.5 or more.
•Replacement of lost or damaged eyeglasses for clients 20 years of age or younger.
•One eye exam every 24 months for assessing the need for eyeglasses for adults.
•Unlimited medically necessary eye exams for a diagnosis of illness or injury.
Medicaid clients can select an ophthalmologist or therapeutic optometrist for Medicaid eye care benefit services (not surgery) without a referral from a primary care provider or any other type of prior authorization.
PCCM clients may also select therapeutic optometrists for the services listed below without a referral from a primary care provider or any other type of prior authorization:
•Behavioral Health Services. Behavioral health services do not require a primary care provider referral. These services include mental health and substance abuse services by a Medicaid-enrolled psychiatrist, psychologist, licensed professional counselor (LPC), licensed clinical social worker (LCSW), licensed marriage and family therapist (LMFT), and Texas Commission on Alcohol and Drug Abuse (TCADA) licensed facility.
Refer to: "Behavioral Health Services" .
"Psychiatric Services" .
"Psychologist" .
"Licensed Professional Counselor (LPC)" .
"Licensed Clinical Social Worker (LCSW)" .
"Licensed Marriage and Family Therapist (LMFT)" .
•Case Management for ECI. See "Targeted Case Management for Early Childhood Intervention (ECI)" .
•Case Management for CPW. See "Case Management for Children and Pregnant Women (CPW)" .
•SHARS. Clients may select any qualified provider to access medically necessary and reasonable services to ensure that Medicaid-eligible children with disabilities receive the benefits mandated by federal and state legislation that guarantees a free and appropriate public education. See "School Health and Related Services (SHARS)" .
•School-Based Clinic Services. Clients may receive services from school-based clinics without a referral from their primary care provider. See "School Health and Related Services (SHARS)" .
•FQHC and RHC After-Hours Care. After-hours care provided by FQHCs and RHCs do not require a referral from the client's primary care provider. After-hours care for FQHCs and RHCs is defined as care provided on weekends, on federal holidays, or before 8 a.m. and after 5 p.m., Monday through Friday. FQHCs and RHCs that provide after-hours services to PCCM clients must submit claims with modifier TU.
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