R414-29-7. Length of Restriction

  (1) A client shall continue participation in the Restriction Program until the client has demonstrated he is not overutilizing services. Once a client is placed in the Restriction Program, a client may request a review for discharge from the Restriction Program after one year. If utilization data supports discharge from the Restriction Program, the client will no longer be enrolled in the program.

  (2) If a client loses Medicaid eligibility, and subsequently re-establishes Medicaid eligibility, the Department shall automatically require the client's participation in the Restriction Program if the loss of eligibility is for less than one year.

  (3) The Department shall assess the client's utilization of services when requested after Restriction has been maintained for at least one year and shall use information such as:

  (a) medical care obtained from multiple practitioners;

  (b) prescriptions obtained from multiple practitioners;

  (c) emergency rooms used for non-emergency services as defined in the Utah Medicaid Table of Authorized Emergency Diagnosis;

  (d) use of multiple emergency rooms;

  (e) concurrent use of medications in the same therapeutic class, when prescribed by different practitioners;

  (f) indications of forged or altered prescriptions;

  (g) use of medical services inconsistent with diagnosis;

  (h) other patterns indicating overutilization.