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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.56 Physician Evaluation and Management (E/M) Services : Referrals
A referral is defined as the transfer of the total or specific care of a patient from one physician to another; a referral does not constitute a consultation. These services must be billed using the appropriate E/M visit code.
When a Texas Medicaid provider refers a Texas Medicaid client to another provider for additional treatment or services, the referring provider must forward notification of the client’s eligibility and his provider identifier. The client must be made aware that the provider he/she is referred to does or does not participate in Texas Medicaid. Some clients not eligible for Medicaid are eligible for family planning through the HHSC Family Planning Program. These clients should be referred to contracted agency providers for family planning services.
All health-care professionals are required by state and federal legislation to refer children who are 35 months of age or younger with developmental delays to early childhood intervention services provided under the authority of the Department of Assistive and Rehabilitative Services (DARS).
Refer to:
Subsection 2.7, “Early Childhood Intervention (ECI) Services,” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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