10 Colo. Code Regs. § 2505-10-8.075
Current through Register Vol. 47, No. 16, August 25, 2024
Section 10 CCR 2505-10-8.075 - CLIENT OVERUTILIZATION PROGRAM8.075.1 Authority is given in 42 CFR 456.3 and 431.54(e) to establish a process that safeguards against unnecessary or inappropriate utilization of care and services. This program allows for the development and review of client utilization profiles, provider service profiles and exception criteria. It identifies excessive patterns in order to rectify overutilization practices of clients, providers and institutions.8.075.2 The Client Overutilization Program restricts Medicaid clients to one designated pharmacy, primary care physician (PCP) or managed care organization (MCO) when there is documented evidence of abuse or overutilization of benefits.8.075.3 DEFINITIONS Client Overutilization Program means a process used to restrict a Medicaid client to a single physician or managed care organization and a single pharmacy to control excessive Medicaid benefits usage.
Overutilization means the improper or excessive utilization of medical care and services that are not medically necessary.
8.075.4 Clients whose utilization of Medicaid benefits without medical necessity has exceeded any one of the following parameters during a quarter shall be subject to placement in the program:1. Use of three or more drugs in the same therapeutic category;.2. Use of three or more pharmacies;3. Use of sixteen or more prescriptions; or4. By referral, review or other analysis that indicates possible overutilization.8.075.4.A. Once the Department identifies a client that falls under 8.075.4, a post-payment review of documented information may be initiated, which includes but is not limited to: 1. Medicaid Management Information System reports;3. Investigative reports;4. Medical record reviews.8.075.4.B. The Department shall inform the client in writing of program placement. The client will be notified of client's appeal rights granted in accordance with 8.057. The client will not be placed in the Overutilization Program until the appeal has been heard and a decision rendered or if no appeal, the appeal timeline has passed. The client has 10 days from the date the notification is mailed to appeal the decision.8.075.4.C. The client will work in conjunction with the Department to select one physician or managed care organization and one pharmacy in which to receive their care. Clients shall be in the Client Overutilization Program for at least 12 consecutive months.8.075.4.D. If a client becomes ineligible for Medicaid benefits during the restricted period, restrictions shall automatically commence for 12 consecutive months from the month eligibility is reestablished unless determined otherwise by the Department.8.075.4.E. The following shall apply when the client has been assigned to the selected physician/MCO and pharmacy:1. The client shall receive notification that identifies the program restrictions and providers. It is the responsibility of the client to request services only from the providers identified on the card. Emergency services are available to the client without the need to prior authorize the services.2. The client shall have the right to a second surgical opinion should surgery be deemed necessary by the designated physician.8.075.4.F. The designated provider shall serve as the case manager for the client. The physician shall authorize and monitor services rendered to the client by any other provider.8.075.4.G. A change in designated providers may be granted if any of the following occur: 1. The provider moves, retires, dies, discontinues Medicaid participation of refuses to continue providing care to the client; or2. The client moves from the physician's service area.8.075.4.H. Restrictions will be rescinded upon the written recommendations of the client's designated provider and the Department. The Department will notify the client in writing of the decision to rescind restrictions. If, after the case review the decision is not to rescind the restrictions the client shall be afforded the opportunity to appeal in accordance with 8057.8.075.5CLIENT REFUSAL TO COOPERATE8.075.5.A. If the client refuses to cooperate with the Department and does not appeal the decision to be placed in the program, the Department shall proceed with program placement. The Department shall notify the client of the providers and the effective date of implementation.