Provider Lock-In Program Sample Clauses

Provider Lock-In Program. The Contractor shall implement for MCO enrollees a lock-in program which restricts enrollees to a single pharmacy and/or other provider type for a reasonable period of time. The Contractor’s program shall include policies, procedures and criteria for establishing the need for the lock-in, based upon whether the enrollee has utilized Medicaid services at a frequency or amount that is not medically necessary. These policies, procedures and criteria must be prior approved by DMAHS and must include the following components to the program: 1. Enrollees shall be notified prior to the lock-in, and must be given the opportunity for a hearing (in accordance with procedures established by the Contractor and approved by DMAHS) before imposing the lock-in. 2. Enrollees must be permitted to choose or change providers for good cause. 3. The restrictions do not apply to emergency services furnished to the enrollee. For pharmacy, a seventy-two (72)-hour emergency supply of medication at pharmacies other than the designated lock-in pharmacy shall be permitted to assure the provision of necessary medication required in an interim/urgent basis when the assigned pharmacy does not immediately have the medication. 4. Care management and education reinforcement of appropriate medication/provider use shall be provided. A plan for an education program for enrollees shall be developed and submitted for review and approval. 5. The continued need for lock-in shall be periodically (at least every two years) evaluated by the Contractor for each enrollee in the program. 6. Prescriptions from all participating prescribers shall be honored and may not be required to be written by the PCP only. 7. The Contractor shall fill medications prescribed by mental health/substance abuse providers, subject to the limitations described in Article 4.4C. 8. The Contractor shall submit quarterly reports on Lock-in participants. See Section A. 7.17 of the Appendices (Table 15). 9. The Contractor shall create a protocol for identifying benefit misuse and abuse by Medicaid/NJ FamilyCare enrollees and restricting or locking-in those enrollees to a single pharmacy and/or other provider type. The Contractor shall establish lock-in policy
Sample 1
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