471 Neb. Admin. Code, ch. 1, § 005

Current through September 17, 2024

Section 471-1-005 - CLIENT RESTRICTED SERVICES PROGRAM

This section applies to medical services in Medicaid fee-for-service and Managed Care

005.01RESTRICTED SERVICES CRITERIA. The Department may restrict a client to obtain Medicaid services only from a designated provider, or renew a period of restricted services, when the client has used Medicaid services at a frequency or amount that is not medically necessary. When evaluating whether a client has used services at a frequency or amount that is not medically necessary, the Department may consider any of the following criteria:

(A) Number, type, or dosage of prescriptions obtained by the client;

(B) Number of prescribers prescribing medication to the client;

(C) Number of pharmacies dispensing to a client;

(D) Number of clinic or emergency room encounters; or

(E) Whether the client displays at-risk behavior, as exhibited by any of the following:

(i) A client with a medical history of seeking and obtaining health care services at a frequency or amount that is not medically necessary; or

(ii) Behaviors or practices that could jeopardize a client's medical treatment or health including, but not limited to:

(1) Forging or altering prescriptions;

(2) Noncompliance with medical or drug and alcohol treatment;

(3) Paying cash for medical services that result in a controlled substance prescription or paying cash for controlled substances;

(4) Arrests for diversion of controlled substance prescriptions;

(5) Positive urine drug screen for illicit drugs or non-prescribed controlled substances;

(6) Negative urine drug screen for prescribed controlled substances; or

(7) Use of a client's Medicaid card for an unauthorized purpose.

005.02DESIGNATION OF RESTRICTED SERVICES PROVIDER(S). The Department will designate a provider to provide services to a client placed into restrictive services. A designated provider must be located within a reasonable distance of, and must be reasonably accessible to, the client.

005.02(A)DURATION OF RESTRICTED SERVICES. A client placed into restricted services must obtain Medicaid services from the designated provider for a period of no more than 12 months. Upon the expiration of a period of restricted services, the Department may renew such period based upon the Department's review of the client's pattern of utilization.

005.02(B)DURATION OF PROVIDER DESIGNATION. A client placed in restricted services must remain with the designated provider, unless any of the following occur:

(i) The designated provider is no longer located within a reasonable distance of, or is no longer reasonably accessible to, the client;

(ii) The designated provider refuses to continue to serve the client;

(iii) The designated provider is no longer enrolled in Medicaid; or

(iv) A change is requested by the client and approved by the Department. A client may request a change of the designated provider no later than 90 days after a designation is made. Such request must be made to the Department in writing.

005.03SERVICES BY PROVIDERS NOT LISTED AS RESTRICTED SERVICES PROVIDERS. Claims for services provided to a restricted services client by other than the designated provider will not be approved, with the following exceptions:

(A) Emergency care is defined as medically necessary services provided to a client who requires immediate medical attention to sustain life or to prevent any condition which could cause permanent disability to body functions;

(B) A primary care provider may refer a restricted services client to a non-designated provider for a specified length of time. Any referral made by a primary care provider to a non-designated provider must be approved by the Department prior to the non-designated provider providing services to the client. Referrals are not required for the following:

(i) Non-emergent medical transportation;

(ii) Home and community based services;

(iii) Mental health and substance abuse services;

(iv) Routine eye exams;

(v) Radiology services;

(vi) Laboratory services;

(vii) Family planning;

(viii) Obstetrics provider services only;

(ix) Dialysis; and

(x) Nursing home services; and

(C) Prescriptions will be covered if prescribed or authorized by a primary care provider, or within the setting of a hospital for non-emergency care if approved by a primary care provider.

005.04RESTRICTED SERVICES NOTIFICATION. The client will be provided notice of the client's placement into restrictive services no fewer than 10 days before restricted services are imposed.

005.04(A)CLIENT APPEAL RIGHTS. A client may appeal the Department's decision to place the client into restricted services. Any appeal must be submitted in writing no later than 90 days after the client is placed into restricted services. If an appeal is submitted within 10 days after notice of the client's placement into restrictive services is mailed, the effective date of the restricted services will be stayed until the appeal has been decided.

005.04(B)CHANGE IN DESIGNATED PROVIDER. A client may appeal the Department's decision to deny the client's request to change a designated provider. Any appeal must be submitted in writing no later than 90 days after the Department's decision.

005.05PHARMACY CLAIMS. Pharmacy claims submitted for prescriptions dispensed to a client in the restricted services program by providers other than a designated provider will not be paid except in a medical emergency. A pharmacy submitting a claim must provide documents indicating a medical emergency existed at the time the prescription was dispensed.

471 Neb. Admin. Code, ch. 1, § 005

Amended effective 11/8/2016.

Amended effective 9/21/2020