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

43.1.15 Referrals for Medicaid-Covered Services

When a provider performing a check up determines that a referral for diagnosis or treatment is necessary for a condition found during the medical check up, that information must be discussed with the parents/guardians. A referral should be made to a provider who is qualified to perform the necessary diagnosis or treatment services. Medicaid Managed Care clients must be referred to their designated primary care provider for further treatment or referral.

A provider needing assistance to find a specialist that accepts clients with Medicaid coverage can call the THSteps Hotline at 1-877-847-8377.

Effort should be made to maintain continuity of care including follow-up to determine that the appointment was kept and that the provider receiving the referral has provided diagnosis and recommendations for further care to the referring provider.

If the provider performing the medical check up can provide treatment for the condition identified, a separate claim (CMS-1500 or UB-04 CMS-1450) may be submitted for the same DOS as the check up with an appropriate established patient office visit for the diagnosis and treatment of the identified problem.

For the acute care claim, an appropriate level CPT code for E/M of established clients should be selected with the diagnosis supporting this additional billing documented. Not all minor illnesses or conditions, such as follow-up of a mild upper respiratory infection, identified during the THSteps medical check up warrant additional billing. The billing of an additional office visit is only appropriate if the additional evaluation and treatment is required and performed for the identified condition(s). This additional service, since it is billed as an acute care claim to the Texas Medicaid Program, is independent of the THSteps medical check up and is viewed as a stand-alone service. Consequently, the medical record must contain documentation that supports the medical necessity and the level of service of the E/M code submitted for reimbursement.

In addition to referrals for conditions discovered during a check up 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 "Eligibility" . 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/PACT referrals. For all age groups, providers must refer clients identified during the THSteps medical check up as needing a diagnostic hearing evaluation for permanent hearing loss or other hearing services, including hearing aids, to a PACT provider. PACT provides services and hearing aids for clients birth through 20 years of age that have permanent hearing loss and are Medicaid clients. Hearing exams and services, including hearing aids (prior authorization needed), are available when medically necessary. Payment for services to eligible clients received through approved PACT providers is made through PACT at DSHS. An appropriate hearing screening is a mandatory part of each medical check up.

•Routine Dental Referrals. Routine dental referrals are required for all clients at 1 year of age and every six months thereafter through 20 years of age (see "THSteps Dental Services" ). Clients younger than 12 months of age are not eligible for routine dental examinations.

•Referrals for Dental Care. If a THSteps medical provider identifies the medical necessity for dental services, the provider must assist the client in planning follow-up care or in making a referral to a THSteps dental provider. Clients younger than 12 months of age also can be seen for emergency dental services by the dentist at any time for trauma, baby bottle tooth decay, or other oral health problems, such as ECCs. Clients birth through 20 years of age may self-refer for dental care.

•Emergency Dental Referrals. If a medical check up 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 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 the "DSHS Health Service Region Contacts"). 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 "Genetic Services" and information about family planning services is available in "Family Planning Services" . If the THSteps medical provider also provides family planning, the provider may inform the client of the availability of these services.

•THSteps-CCP Services Referrals. THSteps-CCP benefits are medically necessary services for which FFP is available and may not currently be benefits of the Texas Medicaid Program (e.g., orthotics, private duty nursing (PDN), and others), as well as expanded coverage of current services that have limitations.

•Women, Infants, and Children (WIC) Referrals. Clients under 5 years of age are eligible for WIC and should be referred to WIC.

Refer to: "Hearing Referrals" for referrals following a hearing screening.

"Medicaid Managed Care" for more information on referrals for providers in areas of the state covered by Medicaid Managed Care.

"THSteps-CCP Overview" for more information.