The following words and terms, when used in the sections under this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.

1. (1) Abuse--Practices that are not medically necessary and consequently result in an unnecessary cost to the Medicaid program; improper or excessive use or treatment.
2. (2) Conflicting--Incompatible, unsuitable for use together because of undesirable chemical or physiological effects. For example, the recipient may receive drugs and/or health care services which may be inadvisable in the presence of certain medical conditions or which conflict with the care ordered by another provider.
3. (3) Contraindicated--To indicate the inadvisability of a medical treatment or procedure. The definition is similar to conflicting.
4. (4) Designated Provider--A provider of medical services enrolled, and in good standing with the Medicaid program to whom the Medicaid recipient is assigned by the Limited Program. The designated provider may include primary care providers and primary care pharmacies.
5. (5) Designated Provider Referral--Communication from the designated provider to another enrolled Medicaid provider requesting certain services be provided to the recipient on Limited Status.
6. (6) Duplicative--To do over or again, without due justification. The word duplicative applies to, but is not limited to, use of drugs and health care services. For example, the recipient received health care services from two or more providers for the same or similar condition(s) in an overlapping time frame or the recipient received two or more similarly acting drugs in an overlapping time frame, which may result in a harmful drug interaction or an adverse reaction.

7. (7) Emergency medical condition--A medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in:

   1. (A) placing the patient's health in serious jeopardy;
   2. (B) serious impairment to bodily functions;
   3. (C) serious dysfunction of any bodily organ or part;
   4. (D) serious disfigurement; or
   5. (E) in the case of a pregnant woman, serious jeopardy to the health of the fetus.
8. (8) Emergency services--Covered inpatient and outpatient services that are furnished by a provider who is qualified to furnish such services under a Medicaid provider agreement and are services which are needed to evaluate or stabilize an emergency medical condition.

9. (9) Excessive Use or Overuse--Exceeding what is usual, medically necessary or customary use of Medicaid services and benefits. Also defined as, but not limited to:

   1. (A) Receipt of treatments, drugs, medical supplies or other Medicaid benefits from one or multiple providers of service in an amount, duration, or scope in excess of which would reasonably be expected to result in a medical or health benefit to the patient; or
   2. (B) Use exceeding the standards and criteria for outpatient prescription drug utilization listed in the compendia and peer reviewed medical literature and/or criteria and standards approved by the Texas Medicaid Drug Utilization Review Board.

10. (10) Fraud--The intentional deception or misrepresentation made by a person with the knowledge that it could result in an unauthorized or medically unnecessary benefit. Fraudulent activities include, but are not limited to:

    1. (A) Lending or altering a Medicaid card for the purpose of obtaining medical benefits for which a person is not legitimately entitled;
    2. (B) Falsely representing medical coverage
    3. (C) Using the Medicaid Identification card of another and altering or duplicating of a Medicaid ID
    4. (D) Furnishing incorrect eligibility or false information to a vendor to obtain treatment
    5. (E) Possessing blank or forged prescription pads
    6. (F) Forging, duplicating or altering a prescription
    7. (G) Knowingly assisting providers in rendering services or defrauding the Medicaid program
    8. (H) Selling or trading, or attempting to sell or trade, drugs or supplies acquired through Medicaid.
11. (11) Limited Program--The Medicaid recipient must access services and benefits through a designated provider. The Medicaid recipient may be limited to a designated provider if, on review, it is found the recipient received duplicative, excessive, contraindicated, or conflicting health care services and/or drugs; or if the review indicates abuse, misuse, or fraudulent actions related to Medicaid benefits and services.
12. (12) Limited Status--The Medicaid recipient's limitation to a designated provider, either a primary care provider or primary care pharmacy through the Limited Program. Recipients are limited for specific periods of time as outlined in §345.2405(c) of this title relating to Limited Status Evaluation.
13. (13) Misuse--To use incorrectly, misapply, or illegally use Medicaid benefits or services. To seek or obtain medical services from a number of like providers and in quantities that exceed the levels considered medically necessary by current medical practices, standards and policies. For example, the medical services are not medically necessary based on the recipient's diagnosis and / or medical condition or conditions that constitute an abuse of Medicaid benefits and services.
14. (14) Primary Care Pharmacy--Pharmacy vendor who agreed to coordinate pharmacy services for recipients with limited status. The pharmacy will ensure that all medications prescribed for the limited recipient are not contraindicated, conflicting, duplicative or excessive and that the client's use does not represent abuse, misuse or fraud.
15. (15) Primary Care Provider--Health care provider who has agreed to oversee the healthcare benefits and services of the recipient. The primary care provider will provide and/or direct all medically necessary care and services for which the recipient is eligible. The primary care provider can include, but is not limited to, a physician, physician group, Advance Practice Nurse, outpatient clinic, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC). The designated primary care provider must be enrolled in Texas Medicaid, not be on payment review status, not be under administrative action, sanction, or investigation for failure to comply with Medicaid rules or acceptable Medicaid practices, and not be under sanction or certain administrative status by the state licensing board.
16. (16) Recipient--Any individual who is deemed eligible to receive Medicaid benefits and services under the Texas Medicaid Program.
17. (17) Referrals--Complaint information supplied to the Limited Program regarding recipient use of Medicaid benefits and services. Sources can include, but are not limited to, providers, state agencies, law enforcement officials or members of the general public. Referrals may also be made to other state agencies and/or Medicaid managed care plans.
18. (18) Services--Allowable and reimbursable medical benefits and services under Title XIX Texas Medicaid Program.
19. (19) Special Message--A notice printed on the Medicaid Identification form to alert medical providers that the recipient's card was used or reportedly as used by an unauthorized person or persons or for an unauthorized purpose. This message is not considered a restriction and may be printed on the Medicaid Identification form with or without the recipient being on limited status.

Source Note:The provisions of this §354.2401 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.