Subsection 144-101-IV-1.08 - CHANGE IN MEMBER STATUS IN RESTRICTION PLAN1.08-1 Continuation of restriction, or modification of enrollment into another Lock-In type, beyond the initial period will be recommended when subsequent annual reviews of the member's records, claims data and national standards, in accordance with the MaineCare Benefits Manual, Chapter IV, by the Member Review Team indicate one or more of the following: A. Evidence of member's failure to comply with the recommended plan of management from the health care providers; B. Evidence of member's continued over-utilization of services without medical necessity, which includes services where payments were denied by MaineCare because the Restriction Plan protocols were not followed; orC. Member's voluntary request to continue the restriction.1.08-2 In cases where the Member Review Team determines that the enrollment in the Restriction Plan should continue beyond the initial period, the member shall be notified in writing by a Notice of Decision. The Notice of Decision shall include the evidence used in the determination and member's right to request an administrative hearing in accordance with the MaineCare Benefits Manual, Chapter I, and Chapter IV.
1.08-3 When the Member Review Team determines that the member's utilization practices have significantly improved, the health care provider restriction shall be terminated on a date designated by the Member Review Team. The member shall be notified by mail of the termination of restriction and the effective date of termination. The Program Integrity Unit shall notify the member that his/her MaineCare utilization shall be monitored to insure that the improved utilization pattern is maintained. Should previously observed over-utilization practices become evident during the monitoring period, the member's case shall be reviewed in accordance with Chapter IV, Section I. C.M.R. 10, 144, ch. 101, ch. IV, § 144-101-IV-1, subsec. 144-101-IV-1.08