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6.1.5 Referrals for Medicaid-Covered Services
When a provider performing a checkup determines that a referral for diagnosis or treatment is necessary for a condition found during the medical checkup, that information must be discussed with the parents/guardians. A referral must be made to a provider who is qualified to perform the necessary diagnosis or treatment services. If the performing provider is competent to treat the condition found, a referral elsewhere is not necessary, unless it is to the primary care provider to assure continuity of care. Medicaid managed care clients must be referred to their designated primary care provider for further treatment or referral.
Providers that need assistance finding a specialist who accepts clients with Medicaid coverage can call the THSteps Hotline at 1-877-847-8377, or they can find one using the Online Provider Lookup on the TMHP website at www.tmhp.com.
Continuity of care is an important aspect of providing services and follow-up. Efforts should be made to determine that the appointment was kept and that the provider who received the referral has provided a diagnosis and recommendations for further care to the referring provider.
In addition to referrals for conditions discovered during a checkup or for specialized care, the following referrals may be used:
• Case Management for Children and Pregnant Women (CPW). CPW provides health-related case management services to eligible children and pregnant women. CPW services include assessing the needs of eligible clients, formulating a service plan, making referrals, problem-solving, advocacy, and follow-up regarding family and client needs. For more information about eligibility, see subsection 3.1.1, "Eligibility" in Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks). To make a referral, providers can call the THSteps Hotline at 1-877-847-8377 or a CPW case management provider in their area. A list of CPW providers can be found on the DSHS Case Management website at www.dshs.state.tx.us/caseman.
•Hearing Services referrals. If the hearing screening returns abnormal results, the client must be referred to a Texas Medicaid provider who is a licensed audiologist or physician who provides audiology services. Clients who are birth through 20 years of age must be referred to a Texas Medicaid provider who is an audiologist or physician who is experienced with the pediatric population and who offers auditory services.
•Routine Dental Referrals. Routine dental referrals are required at 3-month intervals for all clients who are 6 months of age through 35 months of age, based on their caries risk assessment. Routine dental referrals are then performed at 6-month intervals for clients who are 36 months of age through 20 years of age (see subsection 6.1.7, "THSteps Dental Services" in this handbook). When possible, clients should be referred to provider who has completed the required benefit education and is certified by the DSHS Oral Health Program to perform First Dental Home services. Clients who are birth through 5 months of age are not eligible for routine dental examinations.
•Referrals for Dental Treatment. If a THSteps medical provider identifies the medical necessity of dental services, the provider must refer the client to a THSteps dental provider. The THSteps medical provider can accomplish this by providing the parent/guardian a listing of THSteps dentists from the Online Provider Lookup. The parent/guardian can receive assistance in locating a THSteps dentist and assistance with scheduling of dental appointments by contacting the THSteps toll-free helpline at 1-877-847-8377. Clients who are birth through 5 months of age also can be seen for emergency dental services by the dentist at any time for trauma, early childhood caries or other oral health problems. Clients who are birth through 20 years of age may self-refer for dental care.
•Emergency Dental Referrals. If a medical checkup provider identifies an emergency need for dental services, such as bleeding, infection, or excessive pain, the client may be referred directly to a participating dental provider. Emergency dental services are covered at any time for all Medicaid clients who are birth through 20 years of age.
Note: Assistance in coordinating dental referrals can be obtained from the THSteps Hotline at 1-877-847-8377 or the DSHS Regional THSteps Coordinator for the respective region (lists are provided in subsection A.6, "DSHS Health Service Region Contacts" in Appendix A, State and Federal Offices Communication Guide (Vol. 1, General Information)). In cases of both emergency and nonemergency dental services, clients have freedom of choice in selecting a dental provider who is participating in the THSteps Dental Program.
•Family Planning and Genetic Services Referrals. For people eligible for Medicaid needing genetic services or family planning services, a referral should be made. Information about Medicaid-covered genetic services is available in Section 4, "Genetic Services" in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) and information about family planning services is available in Section 3, "Medicaid Title XIX family planning services" in Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook (Vol. 2, Provider Handbooks). If a THSteps medical provider also provides family planning, the provider may inform clients that these services are available.
•Early Childhood Intervention (ECI) Referrals. Federal and state law requires providers to refer children within 2 business days of identification of a suspected developmental delay or disability to the local ECI program for children who are birth through 35 months of age. The provider may call the local ECI Program or the DARS Inquiries Line at 1-800-628-5115 to make referrals. Children who are 3 years of age or older with a suspected developmental delay or disability should be referred to the local school district.
•Women, Infants, and Children (WIC) Referrals. Clients who are birth through 5 years of age or who are pregnant are eligible for WIC and should be referred to WIC.
Refer to: Subsection 8.1, "Medicaid Managed Care" in Section 8, "Managed Care" (Vol. 1, General Information) for more information about referrals for providers in areas of the state covered by Medicaid Managed Care.
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