Recipient Restriction Program. A Centralized Recipient Restriction (lock-in) Program is in place for the MA Fee-For-Service and the Managed Care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI). The PH-MCO agrees to maintain a Recipient Restriction Program to interface with the Department’s Recipient Restriction Program, to provide for appropriate professional resources to manage the Program and to cooperate with the Department in all procedures necessary to restrict Members. The Department has the sole authority to restrict Recipients and has oversight responsibility of the PH-MCO’s Recipient Restriction Program. The PH-MCO is required to obtain approval from the Department prior to implementing a restriction, including approval of written policies and procedures and correspondence to Recipients. The PH-MCO’s process includes: Identifying Members who are overutilizing and/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 Member should be restricted to obtaining services from a single, designated Provider for a period of five years. Forwarding case information and supporting documentation to BPI at the address below, for review to determine appropriateness of restriction and to approve the action. Upon BPI approval, sending notification via certified mail to Member of proposed restriction, including reason for restriction, effective date and length of restriction, name of designated Provider(s) and option to change Provider, with a copy to BPI. Sending notification of Member’s restriction to the designated Provider(s) and the County Assistance Office. Enforcing the restrictions through appropriate notifications and edits in the claims payment system. Preparing and presenting case at a DPW Fair Hearing to support restriction action. Monitoring subsequent utilization to ensure compliance. Changing the selected Provider per the Member’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 Member restriction from the previous delivery system as a Member enrolls in the Managed Care Organization, with written notification to BPI. Reviewing the Member’s services prior to the end of the five-year period of restriction to determine if the restriction should be removed or maintained...
Recipient Restriction Program. A Centralized Recipient Restriction (lock-in) Program is in place for the MA FFS and the Managed Care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI). The PH-MCO will maintain a Recipient Restriction Program to interface with the Department’s Recipient Restriction Program, will provide for appropriate professional resources to manage the Program and to cooperate with the Department in all procedures necessary to restrict Recipients. In accordance with 42 C.F.R. §431.54(e), the restrictions do not apply to emergency services furnished to the Recipient. The Department has the sole authority to restrict Recipients and has oversight responsibility of the PH-MCO’s Recipient Restriction Program. The PH-MCO must obtain approval from the Department prior to implementing a restriction, including approval of written policies and procedures and correspondence to Members. The PH-MCO’s process must include: • Designating a Recipient Restriction Coordinator within the MCO to manage processes. • Identifying Members who are overutilizing and/or misutilizing medical services, receiving unnecessary services or may be defrauding the MA program. • Evaluating the degree of abuse including review of pharmacy and medical claims/encounter history, diagnoses and other documentation, as applicable. • Offering a voluntary restriction to a member to protect his/her medical card from alleged misuse. For example, a voluntary restriction can be imposed when a member loses their card or believes their benefits are being used by someone other than themselves. A voluntary restriction may be ended at any time. • Proposing whether the Member should be restricted to obtaining services from a single, designated Provider for a period of five years. • Forwarding case information and supporting documentation to BPI at the address below or via secure electronic method, for review to determine appropriateness of restriction and to approve the action. • Forwarding case information to BPI for allegations of member fraud.
Recipient Restriction Program. The CHC-MCO must have a process to have PCPs promptly see Participants who presented to an ED but did not require or receive services for those symptoms prompting the ED visit.
Recipient Restriction Program. If Provider participates in the Medical Assistance Program, Provider shall cooperate with Health Plan’s and DHS’s Medicaid recipient restriction program.
Recipient Restriction Program. BPI manages a Centralized Recipient Restriction (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 Recipient Restriction (Lock-in) Program to interface with the Department’s Recipient Restriction (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. In accordance with 42 CFR § 431.54(e), the restrictions do not apply to emergency services furnished to the Participant. 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: • Designating a Recipient Restriction Coordinator within the CHC-MCO to manage processes. • Identifying Participants who are overutilizing or misutilizing medical services, receiving unnecessary services or may be defrauding the MA program. • Offering a voluntary restriction to a participant to protect his/her medical card from alleged misuse. A voluntary restriction can end at any time. • Evaluating the degree of abuse including review of pharmacy, medical and inpatient claims/encounter history, diagnoses and other documentation, as applicable. • Proposing whether the Participant should be restricted to obtaining services from a single, designated Provider for a period of five (5) years. • Forwarding case information and supporting documentation to BPI at the address below or via secure electronic method for review to determine appropriateness of restriction and to approve the action. • Forwarding case information to BPI for allegations of participant fraud. • Upon BPI approval, sending notification via mail to the Participant of the proposed Lock-in, including reason(s), effective date and length of Lock- in, name of designated Provider(s), option to change Provider(s) and appeal rights, with a copy to BPI. • Sending notification of the Participant’s Lock-in to the designated Provider(s) and the CAO. • Enforcing Restrictions (Lock-ins) through appropriate notifications and edits in the claims payment system. • Preparing and presenting the case at a DHS Fair Hearing to support Lock- in action. • Monitoring subsequent utilization to ensure compliance. • Changing the selected Provider per the Participant, Department or Provider’s ...
Recipient Restriction Program. The Contractor agrees to maintain a recipient restriction program to interface with the Department's recipient restriction program and provide for appropriate professional resources to identify and monitor Member fraud and Member abuse and perform the necessary administrative activities to maintain accurate records and comply with state and federal requirements.
Recipient Restriction Program. Provider agrees to cooperate with Sponsor and DPW with regard to the DPW’s Recipient Restriction Program. The specifics of the program are defined in the Provider Manual. ATTACHMENT D CHIP Product Regulatory Requirements The following are the statutory and regulatory requirements for participation in the Avesis CHIP Dental Program for Sponsor, as may be amended from time to time. To the extent that the requirements set forth on this Attachment conflict with the provisions of the Agreement, the terms of this Attachment shall control.
