Common use of Recipient Restriction Program Clause in Contracts

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 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 Participant Lock-in from the previous delivery system as a Participant enrolls in an 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. • Submitting a participant’s claim data to BPI, upon request, within ten (10) business days. • Performing necessary administrative activities to maintain accurate records. • Educating Participants and Providers about the Lock-in program, including explanations in handbooks and printed materials. MA Participants may appeal a Lock-in by requesting a DHS Fair Hearing, but may not file a Complaint or Grievance with the CHC-MCO. A request for a DHS Fair Hearing must be in writing, signed by the Participant and sent to: Department of Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction P.O. Box 2675 Harrisburg, Pennsylvania 00000-0000 Phone number: (000) 000-0000

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 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 Participant Lock-in from the previous delivery system as a Participant enrolls in an 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. • Submitting a participant’s claim data to BPI, upon request, within ten (10) business days. • Performing necessary administrative activities to maintain accurate records. • Educating Participants and Providers about the Lock-in program, including explanations in handbooks and printed materials. MA Participants may appeal a Lock-in by requesting a DHS Fair Hearing, but may not file a Complaint or Grievance with the CHC-MCO. A request for a DHS Fair Hearing must be in writing, signed by the Participant and sent to: Department of Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction P.O. Box 2675 HarrisburgX.X. Xxx 0000 Xxxxxxxxxx, Pennsylvania Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

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 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 Participant Lock-in from the previous delivery system as a Participant enrolls in an 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. • Submitting a participant’s claim data to BPI, upon request, within ten (10) business days. • Performing necessary administrative activities to maintain accurate records. • Educating Participants and Providers about the Lock-in program, including explanations in handbooks and printed materials. MA Participants may appeal a Lock-in by requesting a DHS Fair Hearing, but may not file a Complaint or Grievance with the CHC-MCO. A request for a DHS Fair Hearing must be in writing, signed by the Participant and sent to: Department of Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction P.O. Box 2675 Harrisburg, Pennsylvania 00000-0000 Phone number: (000) 000-0000.