Participant Lock-in Program Sample Clauses

Participant Lock-in Program. BPI manages a Centralized Recipient Lock-in Program for the MA FFS and the managed care delivery systems. The Department is solely responsible for restricting Participants. The CHC-MCO will maintain a Participant Restriction Program to interface with the Department’s Recipient Lock-in Program, and will provide for appropriate professional resources to manage the CHC-MCO program and to cooperate with the Department in all procedures necessary to restrict Participants. The CHC-MCO must obtain approval from the Department prior to implementing a Lock-in, including approval of written policies and procedures and correspondence to Participants. The CHC-MCO’s process must include: • Identifying Participants who are overutilizing or misutilizing medical services. • Evaluating the degree of abuse including review of pharmacy and medical claims history, diagnoses and other documentation, as applicable. • Proposing whether the Participant should be restricted to obtaining services from a single, designated Provider for a fixed period. • Forwarding case information and supporting documentation to BPI for review to determine appropriateness of lock-in and to approve the action. • Upon BPI approval, sending notification via certified mail to Participant of proposed Lock-in, including reason, effective date and length of Lock-in, name of designated Provider(s) and option to change Provider, with a copy to BPI. • Sending notification of Participant’s Lock-in to the designated Provider(s) and the CAO. • Enforcing Lock-ins through appropriate notifications and edits in the claims payment system. • Preparing and presenting case at a DHS Fair Hearing to support Lock-in action. • Monitoring subsequent utilization to ensure compliance. • Changing the selected Provider per the Participant’s or Provider’s request, within thirty (30) days from the date of the request, with prompt notification to BPI through the Intranet Provider change process. • Continuing a Participant Lock-in from the previous delivery system as a Participant enrolls in a MCO, with written notification to BPI. • Reviewing the Participant’s services prior to the end of the Lock-in period to determine if the Lock-in should be removed or maintained, with notification of the results of the review to BPI, Participant, Provider(s) and CAO. • Performing necessary administrative activities to maintain accurate records. • Educating Participants and Providers to the Lock-in program, including explanations in handbooks a...