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8.6.16 Referrals
PCCM primary care providers function as the medical home for PCCM clients. Primary care providers are responsible for arranging and coordinating appropriate referrals to other providers, including specialists, and for managing, monitoring, and documenting the services of other providers. Newly selected primary care providers can call the TMHP Contact Center at 1-800-925-9126 to request referrals for visits. These providers can also request a specialist referral on behalf of a new client if the visit results in the need for a specialist. Referrals from the new primary care provider to a specialist can be issued as soon as the TMHP system reflects that a primary care provider change has already been confirmed.
Referrals are an integral component of PCCM's health-care delivery program. Referrals ensure that clients gain access to all necessary and appropriate covered services and that care is delivered in the most clinically suitable and cost-effective setting.
Referral procedures are designed to capture the information needed to support and manage the utilization of services by the provider network. Proper documentation of referrals is necessary for accurate medical record keeping.
Primary care providers are responsible for the appropriate coordination and referral of PCCM clients for the following services:
• CPW case management services
•DARS case management services
•ECI targeted case management services
•Mental retardation targeted case management
•SHARS
•Texas Commission for the Blind case management services
•THSteps medical case management
•THSteps dental (including orthodontics)
•Tuberculosis services
•Medicaid VDP
A primary care provider who has been selected by a PCCM client, but the primary care provider change is not yet in effect, can make referrals to specialists while the change is pending by calling the PCCM Provider Helpline at 1-888-834-7226.
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