Section 11. Identification Of Candidates

All medicaid recipients are potential candidates for inclusion in medical management, whether enrolled in Salud! or covered under medicaid fee-for-service. Recipients are identified as candidates for review by HCA, the MCO, a provider or other appropriate entities. The following situations may indicate a need for medical management: A. individuals who overutilize medical services; B. individuals who are habitually non-compliant and miss appointments, or who frequently seek unauthorized treatment or care; and C. individuals who frequently change PCPs or simultaneously utilize multiple pharmacy providers; D. individuals who regularly utilize emergency room services for inappropriate, non-emergency care.