Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter K - MEDICAID RECIPIENT UTILIZATION REVIEW AND CONTROL
Section 354.2403 - Monitoring and Review

Universal Citation: 1 TX Admin Code ยง 354.2403

Current through Reg. 49, No. 38; September 20, 2024

(a) The Health and Human Services Commission (HHSC), in accordance with the Code of Federal Regulations, Chapter 42, §431.54(e), conducts a review and analysis of data and/or incoming referrals, such as referrals from medical providers, managed care organizations, state agencies, law enforcement officials, or members of the general public, to identify Texas Medicaid eligible recipients for lock-in.

(1) HHSC may impose a lock-in if it finds that:
(A) a recipient received duplicative, excessive, contraindicated, or conflicting health care services, including drugs; or

(B) a review indicates abuse, misuse or fraudulent actions related to Medicaid benefits and services.

(2) All Texas Medicaid eligible recipients are subject to lock-in regardless of age, program type, or Medicare eligibility.

(b) HHSC may continue the lock-in, change a designated provider(s), and/or take other interventions based on:

(1) utilization pattern(s) indicating excessive use or overuse;

(2) abuse, misuse, or fraud related to Medicaid services or benefits;

(3) non-compliance resulting in receipt of services or medications from one or more non-designated providers in the absence of a designated provider referral or emergency medical condition, including cash payment for services, or obtaining services through illicit methods that result in overutilization or duplicative medication or services;

(4) a designated provider's recommendation to continue the lock-in because the recipient demonstrated non-compliant behavior; or

(5) any change in designated provider due to the recipient's or provider's non-compliance.

(c) HHSC may terminate a recipient's lock-in status for:

(1) the lack of a designated provider accepting responsibility for the recipient; or

(2) evidence of medical necessity provided by the recipient or the designated provider.

(d) The recipient or designated provider may request a medical review of the lock-in at any time.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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