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4.3.2.3 Selection of Designated Provider, Pharmacy
Traditional Medicaid clients identified for limited status can participate in the selection of one primary care provider, primary care pharmacy, or both from a list of participating Medicaid providers. Eligible providers cannot be under administrative action, sanction, or investigation. In general, the designated primary care provider's specialty is general practice, family practice, or internal medicine. Other specialty providers may be selected on a case-by-case basis. Primary care providers can include, but are not limited to: a physician, physician assistant, physician group, advanced practice nurse, outpatient clinic, rural health clinic (RHC), or federally qualified health center (FQHC).
Medicaid Managed Care clients identified for limited status can participate in the selection of pharmacy providers only from participating Medicaid providers who are not under administrative action, sanction, or investigation.
If the client does not select a primary care provider and/or primary care pharmacy, HHSC chooses one for the client.
When a candidate for the designated provider is determined, HHSC contacts the provider by letter. When the provider agrees to be the designated provider, HHSC sends letters of confirmation to the designated provider and the client confirming the name of the client, primary care provider or primary care pharmacy, and the effective date of the limited arrangement.
Claims for provider services for traditional Medicaid clients must include the provider identifier for the designated primary care provider as the billing or performing provider or a referral number in the prior authorization number (PAN) field.
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