Current through September 17, 2024
This section applies to medical services in Medicaid
fee-for-service and Managed Care
005.01
RESTRICTED SERVICES
CRITERIA. The Department may restrict a client to obtain Medicaid
services only from a designated provider, or renew a period of restricted
services, when the client has used Medicaid services at a frequency or amount
that is not medically necessary. When evaluating whether a client has used
services at a frequency or amount that is not medically necessary, the
Department may consider any of the following criteria:
(A) Number, type, or dosage of prescriptions
obtained by the client;
(B) Number
of prescribers prescribing medication to the client;
(C) Number of pharmacies dispensing to a
client;
(D) Number of clinic or
emergency room encounters; or
(E)
Whether the client displays at-risk behavior, as exhibited by any of the
following:
(i) A client with a medical
history of seeking and obtaining health care services at a frequency or amount
that is not medically necessary; or
(ii) Behaviors or practices that could
jeopardize a client's medical treatment or health including, but not limited
to:
(1) Forging or altering
prescriptions;
(2) Noncompliance
with medical or drug and alcohol treatment;
(3) Paying cash for medical services that
result in a controlled substance prescription or paying cash for controlled
substances;
(4) Arrests for
diversion of controlled substance prescriptions;
(5) Positive urine drug screen for illicit
drugs or non-prescribed controlled substances;
(6) Negative urine drug screen for prescribed
controlled substances; or
(7) Use
of a client's Medicaid card for an unauthorized
purpose.
005.02
DESIGNATION OF RESTRICTED
SERVICES PROVIDER(S). The Department will designate a provider to
provide services to a client placed into restrictive services. A designated
provider must be located within a reasonable distance of, and must be
reasonably accessible to, the client.
005.02(A)
DURATION OF RESTRICTED
SERVICES. A client placed into restricted services must obtain
Medicaid services from the designated provider for a period of no more than 12
months. Upon the expiration of a period of restricted services, the Department
may renew such period based upon the Department's review of the client's
pattern of utilization.
005.02(B)
DURATION OF PROVIDER DESIGNATION. A client placed in
restricted services must remain with the designated provider, unless any of the
following occur:
(i) The designated provider
is no longer located within a reasonable distance of, or is no longer
reasonably accessible to, the client;
(ii) The designated provider refuses to
continue to serve the client;
(iii)
The designated provider is no longer enrolled in Medicaid; or
(iv) A change is requested by the client and
approved by the Department. A client may request a change of the designated
provider no later than 90 days after a designation is made. Such request must
be made to the Department in writing.
005.03
SERVICES BY PROVIDERS NOT
LISTED AS RESTRICTED SERVICES PROVIDERS. Claims for services
provided to a restricted services client by other than the designated provider
will not be approved, with the following exceptions:
(A) Emergency care is defined as medically
necessary services provided to a client who requires immediate medical
attention to sustain life or to prevent any condition which could cause
permanent disability to body functions;
(B) A primary care provider may refer a
restricted services client to a non-designated provider for a specified length
of time. Any referral made by a primary care provider to a non-designated
provider must be approved by the Department prior to the non-designated
provider providing services to the client. Referrals are not required for the
following:
(i) Non-emergent medical
transportation;
(ii) Home and
community based services;
(iii)
Mental health and substance abuse services;
(iv) Routine eye exams;
(v) Radiology services;
(vi) Laboratory services;
(vii) Family planning;
(viii) Obstetrics provider services
only;
(ix) Dialysis; and
(x) Nursing home services; and
(C) Prescriptions will be covered
if prescribed or authorized by a primary care provider, or within the setting
of a hospital for non-emergency care if approved by a primary care
provider.
005.04
RESTRICTED SERVICES NOTIFICATION. The client will be
provided notice of the client's placement into restrictive services no fewer
than 10 days before restricted services are imposed.
005.04(A)
CLIENT APPEAL
RIGHTS. A client may appeal the Department's decision to place the
client into restricted services. Any appeal must be submitted in writing no
later than 90 days after the client is placed into restricted services. If an
appeal is submitted within 10 days after notice of the client's placement into
restrictive services is mailed, the effective date of the restricted services
will be stayed until the appeal has been decided.
005.04(B)
CHANGE IN DESIGNATED
PROVIDER. A client may appeal the Department's decision to deny
the client's request to change a designated provider. Any appeal must be
submitted in writing no later than 90 days after the Department's
decision.
005.05
PHARMACY CLAIMS. Pharmacy claims submitted for
prescriptions dispensed to a client in the restricted services program by
providers other than a designated provider will not be paid except in a medical
emergency. A pharmacy submitting a claim must provide documents indicating a
medical emergency existed at the time the prescription was dispensed.
