Subsection 144-101-IV-1.04 - ENROLLMENT OF MEMBERS IN THE RESTRICTION PLAN1.04-1 Identification of Members A. The Program Integrity Unit will identify members who appear to be obtaining health care services that are not medically necessary. Members who are suspected of obtaining health care services that are not medically necessary may be identified by the following sources: 1. Referrals or complaints from members, providers, professional associations, health care professionals and other citizens;2. Referrals from the Department of Health and Human Services ("DHHS"), Office of MaineCare Services, Fraud Investigation and Recovery Unit, the Department of Attorney General, Health Care Crimes Unit, third party payers, State of Maine Board of Pharmacy, the Health and Human Services Office of Inspector General (OIG), Center for Medicare and Medicaid Services (CMS), State and local law enforcement agencies, and any other State or Federal agency;3. Computer generated reports that identify members who may be over-utilizing or inappropriately using health care services.B. Following the identification of members who appear to utilize health care services that are not medically necessary, the Program Integrity Unit may: 1. Analyze the computer-generated profiles of the member's reimbursed health care services for the previous six (6) months, or longer if indicated;2. Review the member's clinical records to document the medical necessity as well as the frequency of services billed, and if necessary;3. Communicate with the key providers to determine if over-utilization is occurring.C. Upon completion of the initial review process, DHHS or its Authorized Agent may contact the member who appears to have over-utilized health care services, to discuss the member's pattern of utilization of health care services. During the contact, the DHHS or its Authorized Agent shall review a summary of the member's primary care provider, pharmacy and hospitalization or other service usage and the member shall be given an opportunity to explain his or her utilization pattern. In addition to explaining the Restriction Plans, DHHS or its Authorized Agent may also provide information on how to obtain appropriate health care services or refer the member to an appropriate agency to obtain services for an identified problem.D. DHHS or its Authorized Agent shall make notes to document the content of the contact, member responses and any referrals. DHHS or its Authorized Agent shall provide the member with a contact name and office telephone number as resources.E. DHHS or its Authorized Agent shall refer the case to the Member Review Team for evaluation in cases where no apparent medical necessity for the health care services exists and/or over-utilization continues.1.04-2 Member Review Team - Case Evaluation The Member Review Team shall review cases referred under the preceding Section to evaluate the utilization and medical necessity of the health care services rendered to members. The Member Review Team shall summarize its findings and recommendations in writing. The Team may recommend:
A. That the member be monitored by DHHS or its Authorized Agent until more documentation and information is available. B. That DHHS or its Authorized Agent contact the member to discuss, verbally or through written communication, the member's health care utilization and concerns. The DHHS or its Authorized Agent will inform the member of the benefits of proper health care utilization and assist the member, if necessary, in securing a health care provider. The Unit representative will also explain the Restriction Plans that could be implemented should the current pattern of utilization continueC. That the member be enrolled in one or more of the four types of Lock-In of the Restriction Plan for restriction to a health care provider, pharmacy, hospital and/or other provider as necessary in order to improve the member's health care benefits usage. The Team may recommend an initial enrollment in the Restriction Plan for a period not to exceed twenty-four (24) months. Subsequent re-enrollment periods, if necessary, are limited to twelve (12) month periods.1.04-3 Member Review Team -Plan CriteriaA. Restriction Plan Criteria The Team may elect to enroll the member into the Restriction Plan if the member has exceeded medically necessary utilization of medical services or benefits. The Team determines over-utilization on a case-by-case basis that includes an evaluation of the member's medical condition and need for services as determined using relevant information including but not limited to the medical record, claims data and national standards for best practices. The member must retain reasonable access to MaineCare services of adequate quality, including consideration for geographic location and reasonable travel time.
1.04-4 Member Notification If the Member Review Team's decision is to enroll the member in the Restriction Plan, the Program Integrity Unit shall mail a Notice of Decision to the member and provide the member with:
2. A summary of the evidence upon which the Team's decision was based, 3. The effective date of the restriction and/or enrollment into the Plan, 4. Citation of the rules supporting the Team's decision, 5. A health care provider and/or prescriber designation form, and 6. Notice of the member's right to request an administrative hearing and appeal the Team's determination in accordance with the Maine Medical Assistance Manual, Chapter I, and Chapter IV. B. The member shall have thirty (30) days from the receipt of the Notice of Decision to complete the health care provider and/or prescriber designation form and return it to the Team. If the member fails to return the completed health care provider and/or prescriber designation form or otherwise notify the Program Integrity Unit of his/her designation of health care providers and/or prescriber, staff of the Program Integrity Unit shall select the member's health care providers and/or prescriber based on the member's medical needs and geographic location. C. Selection of the health care provider(s) and/or prescriber by the Program Integrity Unit staff or through oral notice by the member shall be so documented in the member's file. Enrollment in the Restriction Plan shall not begin until after the member has had an opportunity for an administrative hearing, if requested. If a hearing is not requested by the member within thirty (30) days of the date of the Notice of Decision, then the member's enrollment in the Restriction Plan shall become effective immediately upon confirmation with the participating health care providers.1.04-5 Provider Notification The Program Integrity Unit will contact by telephone each health care provider and/or prescriber selected, to explain the Restriction Plan and solicit the provider's participation and cooperation. If the provider agrees to participate as the health care provider and/or prescriber for the member, a follow-up letter shall be sent by the Program Integrity Unit to the provider confirming his/her participation and the date on which the restriction shall begin.
C.M.R. 10, 144, ch. 101, ch. IV, § 144-101-IV-1, subsec. 144-101-IV-1.04