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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 2 Overview of Medicaid Managed Care : 2.4 PCP/Main Dentist Guidelines for Medicaid Managed Care Clients

2.4
In Medicaid managed care, eligible Medicaid clients choose a primary care provider (PCP) or a main dentist who will work with the client to coordinate the client’s health care or dental services.
The managed care client’s PCP/main dentist is responsible for the following:
Refer to:
Primary care includes ongoing responsibility for preventive health or dental care, health or dental maintenance, treatment of illness and injuries, and the coordination of access to needed specialist providers or other services.
PCPs/main dentists can choose to contract with various MCOs or dental plans.
Provider types who are eligible to serve as a PCP include:
The following provider types are eligible to serve as a main dentist:
The PCP or main dentist either furnishes or arranges for most of the client’s health-care or dental-care needs, including well-checkups, office visits, referrals, outpatient surgeries, hospitalizations, and health- and dental-related services.
Although PCPs are encouraged to assist clients in accessing these services, Medicaid managed care enrollees may self-refer for the following services:
Early Childhood Intervention (ECI) targeted case management

Texas Medicaid & Healthcare Partnership
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