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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 : Exceptions to Lock-in Status
Lock-in clients may go to any provider for the following services or items:
For referrals or questions, contact:
Office of Inspector General
Lock-in Program - MC 1323
PO Box 85200
Austin, TX 78708
If an emergency medical condition occurs, the lock-in restriction does not apply. The term emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain), such that the absence of immediate medical attention could reasonably be expected to result in:
A provider who sends in an appeal because a claim was denied with explanation of benefits (EOB) 00066 must include the performing provider identifier, not just a name or group provider identifier. Appeals without a performing provider identifier are denied. The NPI of the designated provider must be entered in the appropriate paper or equivalent electronic field for nonemergency inpatient and outpatient claims to be considered for reimbursement.
Only when the designated provider or designated provider representative has given permission for the client to receive nonemergency inpatient and/or outpatient services, including those provided in an emergency room, can the facility use the designated provider’s NPI for billing.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.