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December 2016 Texas Medicaid Provider Procedures Manual

Section 4: Client Eligibility : 4.4 Restricted Medicaid Coverage : 4.4.2 Client Lock-in Program

Texas Medicaid fee-for-service clients can be required to use a designated primary care provider and/or a primary care pharmacy.
The client is assigned to a designated provider for access to medical benefits and services when one of the following conditions exists:
After analysis through the neural network component of the Medicaid Fraud and Abuse Detection System (MFADS), qualified medical personnel validate the initial identification and determine candidates for lock-in status. The validation process includes consideration of medical necessity. For the lock-in status designation, medical necessity is defined as the need for medical services to the amount and frequency established by accepted standards of medical practice for the preservation of health, life, and the prevention of more impairments.
Except for specialist consultations, services rendered to a client by more than one provider for the same or similar condition during the same time frame may not be considered medically necessary.

Texas Medicaid & Healthcare Partnership
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