1. (a) The Texas Department of Health (department) controls inappropriate use of medical services by recipients. A recipient has the right to discuss his or her use of medical services with department staff. The department uses the following control methods.

   1. (1) Voluntary reduction request. The department notifies the recipient by letter that the recipient's use of Medicaid services has been identified as possibly unnecessary, excessive, or inappropriate and requests that the recipient voluntarily reduce unnecessary, excessive, or inappropriate utilization in order to avoid more restrictive measures.
   2. (2) Limited status. The department may limit a recipient to a designated provider to coordinate the recipient's Medicaid services. The department identifies a recipient's use of services exceeding 90% as compared to use of like services by other Medicaid recipients. Recipients are removed from limited status when their utilization of medical services no longer meets the criteria for limited enrollment. The recipient or recipient's provider may request a medical review to consider removal of the recipient from the limited program at any time.
2. (b) Provider. A physician of any specialty who is enrolled as a Medicaid provider and who is not on payment review status or under investigation for failure to comply with Medicaid rules or acceptable Medicaid practices may serve as a limited primary care physician. The primary care physician may refer the recipient for other medical services or to other medical specialties as needed. A pharmacist enrolled as a Medicaid provider serves as a coordinator of pharmacy services for recipients enrolled in the limited program.

Source Note:The provisions of this §354.2405 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.