Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 120 - MEDICAL ASSISTANCE PROGRAMS › Subpart E - RECIPIENT RESTRICTION PROGRAM › Section 120.80 - Recipient Restriction Program

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Effective July 1, 2012, the Recipient Restriction Program (RRP) shall identify
				recipients who unnecessarily utilize medical services. When the Department
				determines, on the basis of statistical norms and the medical judgment of
				individual practitioners and/or pharmacists, or other providers, that a
				Medicaid recipient has received medical services that are not medically
				necessary based on the recipient's diagnoses and/or medical condition or
				conditions or in such a manner as to constitute an abuse of medical privileges
				or Program services, the decision to restrict a recipient to one or more
				primary provider types will be made. For purposes of this Section, "primary
				provider type" means an individual practitioner in any of the following
				licensed or certified health care professions: physician, optometrist,
				chiropractor, pharmacist, dentist, any advanced practice nurse, registered
				nurse, licensed practical nurse, genetic counselor, physical therapist,
				podiatrist, speech therapist, psychologist, audiologist, occupational therapist
				or physician assistant. A primary provider type also means a business entity,
				partnership or group practice comprised of or employing any of the individual
				practitioners listed in this subsection (a). A primary provider type can also
				mean any of the following: hospice provider, home health agency, transportation
				provider, community health agency, imaging service, optical company, optician,
				optometrist, independent laboratory, clinical social worker, Department of
				Human Services-Division of Alcohol and Substance Abuse provider, durable
				medical equipment provider, provider of medical equipment and supplies, case
				management provider, behavioral health professional provider, a provider of
				services authorized under a federal Medicaid waiver, or any other provider of
				medical assistance programs authorized under the Illinois Public Aid Code or
				its administrative rules. The RRP applies to all medical assistance programs
				administered by the Department, with the exception of full risk Managed Care
				Organizations (MCO).
b) Primary and
				Secondary Sources of Recipient Identification
1) The primary source of recipient
				identification shall be the Surveillance and Utilization Review Subsystem
				(SURS) of the Medicaid Management Information System (MMIS). On an ongoing
				basis, SURS analyzes the Medicaid population, determines medical usage per
				recipient and will identify recipients with usages in excess of the established
				norm of recipients in the same category of assistance and like demographic
				areas.
2) Secondary sources of
				identification shall be incoming referrals, such as referrals from medical
				providers, law enforcement officials or members of the general public. All
				referrals shall be reviewed and analyzed. Recipients found to have loaned or
				altered their medical cards for the purpose of obtaining medical benefits for
				which they or other persons are not legitimately entitled; falsely represented
				medical coverage; found in possession of blank or forged prescription pads; or
				who knowingly assisted providers in rendering excessive services or defrauding
				the Medical Assistance Program shall be restricted.