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 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. ● Upon BPI approval, sending notification 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 CAO. ● Enforcing the restrictions through appropriate notifications and edits in the claims payment system. ● Preparing and presenting case at a 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 notification within five business days to BPI through the Intranet Provider change process. ● Continuing a Member restriction from the previous delivery system effective date a Member enrolls in a 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 DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction. A request for a DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section P.O. Box 2675 Harrisburg, Pennsylvania 00000-0000 Phone number: (000) 000-0000

Recipient Restriction Program. ‌ A Centralized Recipient Restriction (lockLock-inIn) 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 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 mis utilizing medical services, receiving unnecessary services or may be defrauding the MA program. ● Evaluating the degree of abuse including review of pharmacy and medical claimsClaims/encounter Encounter history, diagnoses and other documentation, as applicable. ● Offering a voluntary restriction to a member Member to protect his/her medical card from alleged misuse. For example, a voluntary restriction can be imposed when a member 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 fraudMember Fraud. ● Upon BPI approval, sending notification to Member of proposed restriction, at least ten days 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 CAO. ● Enforcing the restrictions through appropriate notifications and edits in the claims Claims payment system. ● Preparing and presenting case at a 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 Days from the date of the request, with notification within five business days Business Days to BPI through the Intranet Provider change process. ● Continuing a Member restriction from the previous delivery system effective date a Member enrolls in a 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 memberMember’s claim Claim data to BPI, upon request, within ten (10) business daysBusiness 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 DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction. A request for a DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section P.O. Box 2675 Harrisburg, Pennsylvania 00000-0000 Phone number: (000) 000-0000

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. ● • Upon BPI approval, sending notification 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 CAO. ● • Enforcing the restrictions through appropriate notifications and edits in the claims payment system. ● • Preparing and presenting case at a 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 notification within five business days to BPI through the Intranet Provider change process. ● • Continuing a Member restriction from the previous delivery system effective date a Member enrolls in a 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 DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction. A request for a DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section P.O. Box 2675 HarrisburgX.X. Xxx 0000 Xxxxxxxxxx, Pennsylvania Xxxxxxxxxxxx 00000-0000 Phone number: (000) 000-0000

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. ● Upon BPI approval, sending notification 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 CAO. ● Enforcing the restrictions through appropriate notifications and edits in the claims payment system. ● Preparing and presenting case at a 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 notification within five business days to BPI through the Intranet Provider change process. ● Continuing a Member restriction from the previous delivery system effective date a Member enrolls in a 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 DHS Fair Hearing. Members may not file a Complaint or Grievance with the PH-MCO regarding the restriction. A request for a DHS Fair Hearing must be in writing, signed by the Member and sent to: Department of Human Services Office of Administration Bureau of Program Integrity Division of Program and Provider Compliance Recipient Restriction Section P.O. Box 2675 Harrisburg, Pennsylvania 00000-0000 Phone number: (000) 000-0000