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Utah Administrative Code (Current through November 1, 2019) |
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R414. Health, Health Care Financing, Coverage and Reimbursement Policy |
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R414-29. Client Review/Education and Restriction Policy |
| R414-29-1. Introduction and Authority |
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Latest version.
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(1) The Client Restriction Program promotes the appropriate use of quality medical services by identifying and correcting overutilization of services. (2) This rule is required by 42 CFR 431.54(e) and 456.3. |
| R414-29-2. Definitions |
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Latest version.
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In addition to the definitions in R414-1, the following definitions apply to this rule: (1) "Overutilize" means use of medical services at a frequency or amount that is above what is medically necessary. (2) "Restriction Case Manager" means a Medical Doctor or Doctor of Osteopathy who agrees to become the primary medical care provider for all of a restricted client's non-emergency medical needs. (3) "Restriction Pharmacy" means the only pharmacy that can receive Medicaid reimbursement for dispensing non-emergency pharmacy items to a restricted client. |
| R414-29-3. Notifying Clients of Overutilization of Services |
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Latest version.
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(1) The Department may require a client to participate in the Restriction Program based on the client's overutilization of services. The Department shall notify the client in writing of its determination. This notice shall: (a) state the factors, or combination of factors, justifying Restriction Program participation; (b) cite the regulation authorizing Restriction Program participation; (c) invite the client to provide additional information justifying the use of services, within ten calendar days after the date the notice is issued; (d) notify the client that, if he fails to submit additional written justification within ten calendar days after the date the notice is issued, the Department shall require his participation in the Restriction Program. (e) invite the client to select a Restriction Case Manager and a Restriction Pharmacy; (f) inform the client that if he fails to contact the Department with a choice within ten calendar days after the date the notice is issued, the Department shall assign a Restriction Case Manager and a Restriction Pharmacy without further notice. (2) If the client submits additional information within ten calendar days after the notice is issued, the Department shall evaluate this information along with the original data, and notify the client in writing of the Department's determination. (3) If the client disagrees with the determination, he may request a hearing. The Department shall provide the client with instructions on how to request a hearing, including a hearing request form. |
| R414-29-4. Restriction Case Manager |
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The client may select a physician as a Restriction Case Manager if the physician agrees to serve in that capacity and if the Department accepts the physician as a Restriction Case Manager. The Restriction Case Manager must develop a written treatment plan the client understands and accepts. |
| R414-29-5. Restriction Pharmacy |
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Latest version.
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The client may select a pharmacy as a Restriction Pharmacy if the pharmacy agrees to serve in that capacity and if the Department accepts the pharmacy as a Restriction Pharmacy. |
| R414-29-6. Changes in Restriction Case Manager or Restriction Pharmacy |
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Latest version.
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(1) When a client requests a change in the Restriction Case Manager or the Restriction Pharmacy, the request may be verbal or written. Before placing the new Restriction Case Manager on the client's case record, the Department must verify that the proposed Restriction Case Manager agrees to the responsibilities of the Restriction Case Manager. (2) The Department must approve all changes in the Restriction Case Manager or the Restriction Pharmacy before the client may use a different Restriction Case Manager or Restriction Pharmacy. Circumstances under which the Department may approve such a change are: (a) client, Restriction Case Manager, or Restriction Pharmacy moves location; (b) Restriction Case Manager or Restriction Pharmacy discontinues or limits practice; (c) Restriction Case Manager, or Restriction Pharmacy requests a change; (d) Department Staff Physician recommends a change, when a periodic assessment of the use of services reveals indications of possible overutilization by the restricted client, the Restriction Case Manager, or both. (3) The Department may mandate a change in the Restriction Case Manager or Restriction Pharmacy whenever it determines that the client: (a) continues to overutilize services despite being under restriction; or (b) is not receiving appropriate care while being managed by the Restriction provider. |
| R414-29-7. Length of Restriction |
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Latest version.
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(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. |