TMPPM 2008 > Texas Medicaid Services > Texas Health Steps (THSteps) > THSteps Medical and Dental Administrative Information

43.1.4.2 Medicaid Managed Care Enrollment

The Medicaid Managed Care Program consists of two types of health-care delivery systems, Primary Care Case Management (PCCM) and health maintenance organization (HMO). THSteps medical providers do not have to enroll with PCCM to be reimbursed for medical check up services provided to PCCM clients. Bills are submitted directly to TMHP, and PCCM clients are free to choose the provider who will perform their THSteps medical check ups.

Under HMOs this same freedom of choice exists; however, providers bill the HMO rather than TMHP. Clients should check with their HMO to see whether they must select a provider in the network.

While preventive services are available in managed care, those provided to clients from birth through 20 years of age must be completed as THSteps medical check ups, including completion of all components as noted in this section, and be submitted with appropriate THSteps procedure codes and THSteps provider identifiers.

Note: Diagnosis and treatment of problems must be provided either by the client's primary care provider or by a provider referred by the client's primary care provider. If a THSteps medical check up is performed by a provider who is not the client's primary care provider, the results of the medical check up should be forwarded to the client's primary care provider so that the client's medical record can be updated, in keeping with the medical home concept.

If an enrolled medical check up provider wants to discontinue participation, the provider must send written notification to the managed care health plan. The provider must also send written notification to TMHP at the following address:

Texas Medicaid & Healthcare Partnership
Provider Enrollment
PO Box 200795
Austin, TX 78720-0795

Refer to: "Provider Enrollment" for more information about enrollment.

"Managed Care" .