TMPPM 2008 > Texas Medicaid Services > Physician > Benefits and Limitations

36.3.5.4 Referrals

A referral is defined as the transfer of the total or specific care of a patient from one physician to another; a referral does not constitute a consultation. These services should be submitted using the appropriate E/M visit code.

When a Texas Medicaid Program provider refers a Texas Medicaid Program client to another provider for additional treatment or services, the referring provider must forward notification of the client's eligibility and his provider identifier. The client must be made aware that the provider he/she is referred to does or does not participate in the Texas Medicaid Program. Some clients not eligible for Medicaid are eligible for family planning through Titles V and XX. These clients should be referred to contracted agency providers for family planning services.

Referral Requirements for Children with Disabilities

All health-care professionals are required by state and federal legislation to refer children younger than 3 years of age with developmental delays to early childhood intervention services provided under the authority of the Department of Assistive and Rehabilitative Services (DARS). Referrals must take place within two business days of identifying a delay in development.

DARS is a coordinated system of services available in every Texas county for children from birth to 3 years of age with developmental delays. DARS has served more than 27,000 children younger than 3 years of age through 70 local programs.

Referrals may be based on professional judgment or a family's concern. A medical diagnosis or a confirmed developmental delay is not required for referrals.

On referral, DARS programs determine eligibility based on screening and assessments. Children are eligible if they meet at least one of the following criteria:

•A delay in one or more areas of development.

•Atypical development. Children who perform within their appropriate age range on test instruments, but whose patterns of development are different from their peers.

•A medically diagnosed condition. Children who have a medically diagnosed condition with a high probability of resulting in developmental delay.

Families and professionals work together to plan appropriate services based on the unique needs of the child and the child's family.

Services that are provided at no cost to families may include:

•Physical, occupational, speech, and language therapy.

•Service coordination.

•Vision services.

•Special instruction.

•Nutrition services.

•Family counseling and education.

•Assistive technology (service and devices).

Providers can refer families for services by calling the local DARS program or the statewide DARS Care Line at 1-800-250-2246. Providers can also obtain brochures or more information by calling the DARS Care Line or visiting the DARS website at www.dars.state.tx.us.