Common use of Recipient Restriction Program Clause in Contracts

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, with notification of the results of the review to BPI, Member, Provider(s) and CAO.  Performing necessary administrative activities to maintain accurate records.  Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction action. A request for a DPW Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

Recipient Restriction Program. A BPI manages a Centralized Recipient Restriction (lockLock-in) Program is in place for the MA Fee-For-Service FFS and the Managed Care managed care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI)systems. The PHDepartment is solely responsible for restricting Participants. The CHC-MCO agrees to will maintain a Recipient Restriction (Lock-in) Program to interface with the Department’s Recipient Restriction (Lock-in) Program, to and will provide for appropriate professional resources to manage the Program CHC-MCO program and to cooperate with the Department in all procedures necessary to restrict MembersParticipants. In accordance with 42 CFR § 431.54(e), the restrictions do not apply to emergency services furnished to the Participant. The Department has the sole authority to restrict Recipients and has oversight responsibility of the PH-MCO’s Recipient Restriction Program. The PH-CHC- MCO is required to must obtain approval from the Department prior to implementing a restrictionLock- in, including approval of written policies and procedures and correspondence to RecipientsParticipants. The PHCHC-MCO’s process includesmust include:  • Designating a Recipient Restriction Coordinator within the CHC-MCO to manage processes. • Identifying Members Participants who are overutilizing and/or 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 pharmacy, medical and medical claims inpatient claims/encounter history, diagnoses and other documentation, as applicable.  • Proposing whether the Member 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, 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 certified mail to Member the Participant of the proposed restrictionLock-in, including reason for restrictionreason(s), effective date and length of restrictionLock- in, name of designated Provider(s) and ), option to change ProviderProvider(s) and appeal rights, with a copy to BPI.  • Sending notification of Memberthe Participant’s restriction Lock-in to the designated Provider(s) and the County Assistance OfficeCAO.  • Enforcing the restrictions Restrictions (Lock-ins) through appropriate notifications and edits in the claims payment system.  • Preparing and presenting the case at a DPW DHS Fair Hearing to support restriction Lock- in action.  • Monitoring subsequent utilization to ensure compliance.  • Changing the selected Provider per the Member’s Participant, Department or Provider’s request, within thirty (30) days from the date of the request, with prompt notification within five (5) business days to BPI through the Intranet Provider change process.  • Continuing a Member restriction Participant Lock-in from the previous delivery system as a Member Participant enrolls in the Managed Care Organizationan MCO, with written notification to BPI.  • Reviewing the MemberParticipant’s services prior to the end of the fiveLock-year in period of restriction to determine if the restriction Lock-in should be removed or maintained, with notification of the results of the review to BPI, MemberParticipant, Provider(s) and CAO.  • Submitting a participant’s claim data to BPI, upon request, within ten (10) business days. • Performing necessary administrative activities to maintain accurate records.  • Educating Members Participants and Providers to about the restriction Lock-in program, including explanations in handbooks and printed materials. MA Recipients have the right to Participants may appeal a restriction Lock-in by requesting a DPW DHS Fair Hearing. Members , but may not file a Complaint or Grievance with the PHCHC-MCO regarding the restriction actionMCO. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member Participant and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 XxxxxxxxxxP.O. Box 2675 Harrisburg, Xxxxxxxxxxxx Pennsylvania 00000-0000 Phone number: (000) 000-0000

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, with notification of the results of the review to BPI, Member, Provider(s) and CAO.  • Performing necessary administrative activities to maintain accurate records.  • Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction action. A request for a DPW Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

Recipient Restriction Program. A BPI manages a Centralized Recipient Restriction (lockLock-in) in Program is in place for the MA Fee-For-Service FFS and the Managed Care managed care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI)systems. The PHDepartment is solely responsible for restricting Participants. The CHC-MCO agrees to will maintain a Recipient Restriction Program to interface with the Department’s Recipient Restriction Lock-in Program, to and will provide for appropriate professional resources to manage the Program CHC-MCO program and to cooperate with the Department in all procedures necessary to restrict MembersParticipants. In accordance with 42 CFR § 431.54(e), the restrictions do not apply to emergency services furnished to the Participant. The Department has the sole authority to restrict Recipients and has oversight responsibility of the PH-MCO’s Recipient Restriction Program. The PHCHC-MCO is required to must obtain approval from the Department prior to implementing a restrictionLock-in, including approval of written policies and procedures and correspondence to RecipientsParticipants. The PHCHC-MCO’s process includesmust include:  Designating a Recipient Restriction Coordinator within the CHC-MCO to manage processes.  Identifying Members Participants who are overutilizing and/or or misutilizing medical servicesservices , 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.  Evaluating the degree of abuse including review of pharmacy and medical claims claims/encounter history, diagnoses and other documentation, as applicable.  Proposing whether the Member Participant should be restricted to obtaining services from a single, designated Provider for a period of five yearsfixed period.  Forwarding case information and supporting documentation to BPI at the address below, 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 certified mail to Member the Participant of the proposed restrictionLock-in, including reason for restrictionreason(s), effective date and length of restrictionLock- in, name of designated Provider(s) and ), option to change ProviderProvider(s) and appeal rights, with a copy to BPI.  Sending notification of Memberthe Participant’s restriction Lock-in to the designated Provider(s) and the County Assistance OfficeCAO.  Enforcing the restrictions Lock-ins through appropriate notifications and edits in the claims payment system.  Preparing and presenting the case at a DPW DHS Fair Hearing to support restriction Lock- in action.  Monitoring subsequent utilization to ensure compliance.  Changing the selected Provider per the MemberParticipant’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 Participant Lock-in from the previous delivery system as a Member Participant enrolls in the Managed Care Organizationan MCO, with written notification to BPI.  Reviewing the MemberParticipant’s services prior to the end of the fiveLock-year in period of restriction to determine if the restriction Lock-in should be removed or maintained, with notification of the results of the review to BPI, MemberParticipant, Provider(s) and CAO.  Submitting a participant’s claim data to BPI, upon request, within ten (10) business days.  Performing necessary administrative activities to maintain accurate records.  Educating Members Participants and Providers to about the restriction Lock-in program, including explanations in handbooks and printed materials. MA Recipients have the right to Participants may appeal a restriction Lock-in by requesting a DPW DHS Fair Hearing. Members , but may not file a Complaint or Grievance with the PHCHC-MCO regarding the restriction actionMCO. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member Participant and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 XxxxxxxxxxP.O. Box 2675 Harrisburg, Xxxxxxxxxxxx Pennsylvania 00000-0000 Phone number: (000) 000-0000

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, with notification of the results of the review to BPI, Member, Provider(s) and CAO.  Performing necessary administrative activities to maintain accurate records.  Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction action. A request for a DPW Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

Recipient Restriction Program. A Centralized Recipient Restriction (lock-in) Program is in place for the MA Fee-For-Service FFS and the Managed Care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI). The PH-MCO agrees to will maintain a Recipient Restriction Program to interface with the Department’s Recipient Restriction Program, to will 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 must obtain approval from the Department prior to implementing a restriction, including approval of written policies and procedures and correspondence to RecipientsMembers. The PH-MCO’s process includesmust include:  Designating a Recipient Restriction Coordinator within the MCO to manage processes.  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, at least ten days in advance, 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 OfficeCAO.  Enforcing the restrictions through appropriate notifications and edits in the claims payment system.  Preparing and presenting case at a DPW DHS 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 Organizationa MCO, 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, with notification of the results of the review to BPI, Member, Provider(s) and CAO.  Performing necessary administrative activities to maintain accurate records.  Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction actionrestriction. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

Recipient Restriction Program. A Centralized Recipient Restriction (lock-in) Program is in place for the MA Fee-For-Service FFS and the Managed Care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI). The PH-MCO agrees to will maintain a Recipient Restriction Program to interface with the Department’s Recipient Restriction Program, to will 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 must obtain approval from the Department prior to implementing a restriction, including approval of written policies and procedures and correspondence to RecipientsMembers. The PH-MCO’s process includesmust include:  • Designating a Recipient Restriction Coordinator within the MCO to manage processes. • 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, at least ten days in advance, 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 OfficeCAO.  • Enforcing the restrictions through appropriate notifications and edits in the claims payment system.  • Preparing and presenting case at a DPW DHS 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 Organizationa MCO, 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, with notification of the results of the review to BPI, Member, Provider(s) and CAOXXX.  • Performing necessary administrative activities to maintain accurate records.  • Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction actionrestriction. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

Recipient Restriction Program. ‌ A Centralized Recipient Restriction (lock-in) Program is in place for the MA Fee-For-Service FFS and the Managed Care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI). The PH-MCO agrees to will maintain a Recipient Restriction Program to interface with the Department’s Recipient Restriction Program, to will 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 must obtain approval from the Department prior to implementing a restriction, including approval of written policies and procedures and correspondence to RecipientsMembers. The PH-MCO’s process includesmust 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 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 belowbelow 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.  Upon BPI approval, sending notification via certified mail to Member of proposed restriction, at least ten days in advance, 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 OfficeCAO.  Enforcing the restrictions through appropriate notifications and edits in the claims payment system.  Preparing and presenting case at a DPW DHS 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 Organizationa MCO, 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, with notification of the results of the review to BPI, Member, Provider(s) and CAO.  Submitting member’s claim data to BPI, upon request, within ten (10) business days.  Performing necessary administrative activities to maintain accurate records.  Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction actionrestriction. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

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, with notification of the results of the review to BPI, Member, Provider(s) and CAO.  • Performing necessary administrative activities to maintain accurate records.  • Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction action. A request for a DPW Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

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 DHS 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, with notification of the results of the review to BPI, Member, Provider(s) and CAO.  Performing necessary administrative activities to maintain accurate records.  Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction action. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

Recipient Restriction Program. ‌ A Centralized Recipient Restriction (lock-in) Program is in place for the MA Fee-For-Service FFS and the Managed Care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI). The PH-MCO agrees to will maintain a Recipient Restriction Program to interface with the Department’s Recipient Restriction Program, to will 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 must obtain approval from the Department prior to implementing a restriction, including approval of written policies and procedures and correspondence to RecipientsMembers. The PH-MCO’s process includesmust include:  • Designating a Recipient Restriction Coordinator within the MCO to manage processes. • 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, at least ten days in advance, 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 OfficeCAO.  • Enforcing the restrictions through appropriate notifications and edits in the claims payment system.  • Preparing and presenting case at a DPW DHS 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 Organizationa MCO, 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, with notification of the results of the review to BPI, Member, Provider(s) and CAO.  • Performing necessary administrative activities to maintain accurate records.  • Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction actionrestriction. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

Recipient Restriction Program. A BPI manages a Centralized Recipient Restriction (lockLock-in) in Program is in place for the MA Fee-For-Service FFS and the Managed Care managed care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI)systems. The PHDepartment is solely responsible for restricting Participants. The CHC-MCO agrees to will maintain a Recipient Restriction Program to interface with the Department’s Recipient Restriction Lock-in Program, to and will provide for appropriate professional resources to manage the Program CHC-MCO program and to cooperate with the Department in all procedures necessary to restrict MembersParticipants. In accordance with 42 CFR § 431.54(e), the restrictions do not apply to emergency services furnished to the Participant. The Department has the sole authority to restrict Recipients and has oversight responsibility of the PH-MCO’s Recipient Restriction Program. The PHCHC-MCO is required to must obtain approval from the Department prior to implementing a restrictionLock-in, including approval of written policies and procedures and correspondence to RecipientsParticipants. The PHCHC-MCO’s process includesmust include:  • Designating a Recipient Restriction Coordinator within the CHC-MCO to manage processes. • Identifying Members Participants who are overutilizing and/or or misutilizing medical servicesservices , 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. • Evaluating the degree of abuse including review of pharmacy and medical claims claims/encounter history, diagnoses and other documentation, as applicable.  • Proposing whether the Member Participant should be restricted to obtaining services from a single, designated Provider for a period of five yearsfixed period.  • Forwarding case information and supporting documentation to BPI at the address below, 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 certified mail to Member the Participant of the proposed restrictionLock-in, including reason for restrictionreason(s), effective date and length of restrictionLock- in, name of designated Provider(s) and ), option to change ProviderProvider(s) and appeal rights, with a copy to BPI.  • Sending notification of Memberthe Participant’s restriction Lock-in to the designated Provider(s) and the County Assistance OfficeCAO.  • Enforcing the restrictions Lock-ins through appropriate notifications and edits in the claims payment system.  • Preparing and presenting the case at a DPW DHS Fair Hearing to support restriction Lock- in action.  • Monitoring subsequent utilization to ensure compliance.  • Changing the selected Provider per the MemberParticipant’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 Participant Lock-in from the previous delivery system as a Member Participant enrolls in the Managed Care Organizationan MCO, with written notification to BPI.  • Reviewing the MemberParticipant’s services prior to the end of the fiveLock-year in period of restriction to determine if the restriction Lock-in should be removed or maintained, with notification of the results of the review to BPI, MemberParticipant, Provider(s) and CAO.  • Submitting a participant’s claim data to BPI, upon request, within ten (10) business days. • Performing necessary administrative activities to maintain accurate records.  • Educating Members Participants and Providers to about the restriction Lock-in program, including explanations in handbooks and printed materials. MA Recipients have the right to Participants may appeal a restriction Lock-in by requesting a DPW DHS Fair Hearing. Members , but may not file a Complaint or Grievance with the PHCHC-MCO regarding the restriction actionMCO. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member Participant and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 XxxxxxxxxxP.O. Box 2675 Harrisburg, Xxxxxxxxxxxx Pennsylvania 00000-0000 Phone number: (000) 000-0000

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 DHS 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, with notification of the results of the review to BPI, Member, Provider(s) and CAO.  • Performing necessary administrative activities to maintain accurate records.  • Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction action. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

Recipient Restriction Program. ‌ A Centralized Recipient Restriction (lock-in) Program is in place for the MA Fee-For-Service FFS and the Managed Care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI). The PH-MCO agrees to will maintain a Recipient Restriction Program to interface with the Department’s Recipient Restriction Program, to will 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 must obtain approval from the Department prior to implementing a restriction, including approval of written policies and procedures and correspondence to RecipientsMembers. The PH-MCO’s process includesmust 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 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 belowbelow 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. • Upon BPI approval, sending notification via certified mail to Member of proposed restriction, at least ten days in advance, 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 OfficeCAO.  • Enforcing the restrictions through appropriate notifications and edits in the claims payment system.  • Preparing and presenting case at a DPW DHS 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 Organizationa MCO, 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, with notification of the results of the review to BPI, Member, Provider(s) and CAO.  • Submitting member’s claim data to BPI, upon request, within ten (10) business days. • Performing necessary administrative activities to maintain accurate records.  • Educating Members and Providers to the restriction program, including explanations in handbooks and printed materials. MA Recipients have the right to appeal a restriction by requesting a DPW DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction actionrestriction. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

Recipient Restriction Program. A BPI manages a Centralized Recipient Restriction (lockLock-in) Program is in place for the MA Fee-For-Service FFS and the Managed Care managed care delivery systems and is managed by the Department’s Bureau of Program Integrity (BPI)systems. The PHDepartment is solely responsible for restricting Participants. The CHC-MCO agrees to will maintain a Recipient Restriction (Lock-in) Program to interface with the Department’s Recipient Restriction (Lock-in) Program, to and will provide for appropriate professional resources to manage the Program CHC-MCO program and to cooperate with the Department in all procedures necessary to restrict MembersParticipants. In accordance with 42 CFR § 431.54(e), the restrictions do not apply to emergency services furnished to the Participant. The Department has the sole authority to restrict Recipients and has oversight responsibility of the PH-MCO’s Recipient Restriction Program. The PH-CHC- MCO is required to must obtain approval from the Department prior to implementing a restrictionLock- in, including approval of written policies and procedures and correspondence to RecipientsParticipants. The PHCHC-MCO’s process includesmust include:  • Designating a Recipient Restriction Coordinator within the CHC-MCO to manage processes. • Identifying Members Participants who are overutilizing and/or 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 pharmacy, medical and medical claims inpatient claims/encounter history, diagnoses and other documentation, as applicable.  • Proposing whether the Member 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, 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 certified mail to Member the Participant of the proposed restrictionLock-in, including reason for restrictionreason(s), effective date and length of restrictionLock- in, name of designated Provider(s) and ), option to change ProviderProvider(s) and appeal rights, with a copy to BPI.  • Sending notification of Memberthe Participant’s restriction Lock-in to the designated Provider(s) and the County Assistance OfficeCAO.  • Enforcing the restrictions Restrictions (Lock-ins) through appropriate notifications and edits in the claims payment system.  • Preparing and presenting the case at a DPW DHS Fair Hearing to support restriction Lock- in action.  • Monitoring subsequent utilization to ensure compliance.  • Changing the selected Provider per the Member’s Participant, Department or Provider’s request, within thirty (30) days from the date of the request, with prompt notification within five (5) business days to BPI through the Intranet Provider change process.  • Continuing a Member restriction Participant Lock-in from the previous delivery system as a Member Participant enrolls in the Managed Care Organizationan MCO, with written notification to BPI.  • Reviewing the MemberParticipant’s services prior to the end of the fiveLock-year in period of restriction to determine if the restriction Lock-in should be removed or maintained, with notification of the results of the review to BPI, MemberParticipant, Provider(s) and CAO.  • Submitting a participant’s claim data to BPI, upon request, within ten (10) business days. • Performing necessary administrative activities to maintain accurate records.  • Educating Members Participants and Providers to about the restriction Lock-in program, including explanations in handbooks and printed materials. MA Recipients have the right to Participants may appeal a restriction Lock-in by requesting a DPW DHS Fair Hearing. Members , but may not file a Complaint or Grievance with the PHCHC-MCO regarding the restriction actionMCO. A request for a DPW DHS Fair Hearing must be in writing, signed by the Member Participant and sent to: Department of Public Welfare Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section X.X. Xxx 0000 Xxxxxxxxxx, Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000