Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 27. Restriction of recipient's choice of providers

7 AAC 43.027. Restriction of recipient's choice of providers

(a) The department may restrict a recipient's choice of medical providers if the department finds that a recipient has used Medicaid services at a frequency or amount that is not medically necessary as provided in (b) and (c) of this section.

(b) In order for a recipient to be identified as a potential candidate for restriction under this section, one of the following must occur:

(1) a referral is made to the department indicating that the recipient has used a medical item or service at a frequency or amount that is not medically necessary;

(2) the recipient receives prescriptions from one or more providers for medication in total average daily doses that exceed those recommended in Drug Facts and Comparisons, 2005, published by Wolters Kluwer Health, Inc., and adopted by reference;

(3) the recipient, during a period of not less than three consecutive months, uses a medical item or service with a frequency that exceeds two standard deviations from the arithmetic mean of the frequency of use of the medical item or service by recipients of medical assistance programs administered by the department who have used the medical item or service as shown in the department's most recent statistical analysis of usage of that medical item or service.

(c) Once a recipient is identified under (b) of this section, the department will conduct an individualized clinical review of the recipient's medical and billing history to determine how the recipient has used the disputed medical item or service and whether that usage was medically necessary. The review must be conducted by a qualified health care professional. The reviewer shall consider the following:

(1) the recipient's age;

(2) the recipient's diagnosis;

(3) complications of the recipient's medical conditions;

(4) the recipient's chronic illnesses;

(5) number of different physicians and hospitals used by the recipient; and

(6) the type of medical care received by the recipient.

(d) If after the review under (c) of this section is complete the reviewer determines that the recipient's use of a medical item or service is not medically necessary, the department will

(1) monitor the recipient's usage for 90 days; or

(2) notify the recipient in writing that the department will restrict a recipient's choice of provider as provided in (e) of this section.

(e) If the department determines that it is necessary to restrict a recipient's choice of provider under (d)(2) of this section, the department will first offer the recipient the opportunity for a fair hearing in accordance with 7 AAC 49. The department may immediately restrict the recipient's choice of providers if the recipient does not request a hearing within 30 days after receiving notice of the department's intent to impose a restriction.

(f) If the department prevails after a fair hearing or the recipient does not request a fair hearing within 30 days after receiving notice of the department's intent to impose a restriction, the department will select one primary care provider and pharmacy within reasonable proximity to the recipient's home. The department will mark the recipient's identification card or medical coupons with the word "RESTRICTED" and the name of the designated provider and pharmacy. The recipient may obtain services and items from only the designated provider and pharmacy, except as follows:

(1) the recipient may receive specialized medical services from another enrolled provider if the designated provider refers the recipient to the other enrolled provider;

(2) the recipient may receive emergency services from any enrolled provider; for purposes of this paragraph, "emergency services" has the meaning given in 7 AAC 43.052(e) .

(g) The department may only restrict provider choice for a reasonable period of time, not to exceed 12 months of eligibility. The department will review the restriction annually. If the department determines that the restriction should extend beyond 12 months of eligibility, the department will provide the recipient notice and an opportunity for a new fair hearing under (d)(2)and (e) of this section.

(h) The designation of the primary care provider or pharmacy under (f) of this section may be changed only if

(1) the primary care provider or pharmacy requests the change;

(2) the primary care provider or pharmacy disenrolls from the Medicaid program;

(3) the recipient moves to a new geographic area; or

(4) the department finds that the recipient does not have reasonable access to Medicaid services of adequate quality.

(i) Except as provided in (f) of this section, the department will pay only a provider designated under this section for the provision of medical services to a recipient whose identification card or medical coupons are marked "RESTRICTED."

(j) In this section, "qualified health care professional" means a health care provider who is licensed under AS 08 and whose area of licensure relates to the service or item identified under (b) of this section.

History: Eff. 6/28/85, Register 94; am 5/28/92, Register 122; readopt 8/7/96, Register 139; am 6/19/2004, Register 170; am 9/23/2005, Register 175

Authority: AS 47.05.010

AS 47.07.050

Editor's note: Drug Facts and Comparisons, 2005, adopted by reference in 7 AAC 43.027(b) , may be obtained from the publisher, Wolters Kluwer Health, Inc., by telephone at 800-223-0554 or 314-216-2100. The book may also be ordered from the publisher at http://www.drugfacts.com or by writing to the following address: Wolters Kluwer Health, Inc., 111 West Port Plaza Drive, Suite 300, St. Louis, Missouri 63146-3098. It may be reviewed at the Department of Health and Social Service's office at 350 Main Street, Room 412, Juneau, Alaska.