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Rule §354.2403 Monitoring And Review

Published: 2015

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(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;
  (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
  (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.

Source Note: The provisions of this §354.2403 adopted to be effective April 2, 2000, 25 TexReg 2817; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4563; amended to be effective April 6, 2003, 28 TexReg 2738; amended to be effective April 2, 2013, 38 TexReg 2095