1. (a) The Texas Department of Health in accordance with federal requirements identifies unnecessary, excessive, or inappropriate use of Medicaid services by a recipient. These determinations are based on comparisons with statewide patterns of use and will take into consideration the necessity for utilization.

2. (b) Reviews are required for a recipient who receives covered Medicaid services when:

   1. (1) use of any Medicaid services exceeds 90% as compared to other Medicaid recipient's use of services; and/or

   2. (2) there is suspected misuse, overuse, abuse or fraudulent use of Medicaid services, which include, but are not limited to:

      1. (A) duplicating or altering prescriptions;
      2. (B) using non-therapeutic prescriptions;
      3. (C) 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;
      4. (D) using the Medicaid Identification card of another and altering or duplication of a Medicaid ID card;
      5. (E) furnishing incorrect eligibility or false information to a vendor to obtain treatment;
      6. (F) selling, trading, or attempting to sell or trade drugs or supplies acquired by Medicaid; or
      7. (G) inappropriate use of emergency room services.

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.