1/9/2024
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Posted by Provider Relations
The Recipient Restriction Program (RRP) is a medical review and administrative mechanism whereby New York State (NYS) Medicaid members with a demonstrated pattern of abusing or misusing NYS Medicaid services may be restricted to a specific healthcare provider (i.e., hospital, clinic, physician) or pharmacy to coordinate services. RRP is administered by the Office of the Medicaid Inspector General (OMIG) in coordination with local Departments of Social Services (LDSS).
When there is a need for a member to be assigned to the RRP, Fidelis Care will contact the appropriate healthcare provider to obtain a verbal and/or written agreement stating the provider agrees to act as the member’s restricted provider. Once the agreement is in place, the provider will receive a notification letter that the member has been restricted to them.
NYS Medicaid members who have been restricted as part of RRP to a designated health care provider or pharmacy are required to receive care only from the designated health care provider or pharmacy. A primary pharmacy is responsible for identifying the ordering prescriber and managing the delivery of medications.
It is important to remember that the primary health care provider, whether a physician, hospital, or clinic, is responsible for the provision of most health care services for the restricted NYS Medicaid member. Claims submitted for a restricted NYS Medicaid member will be denied if the information of the primary care provider is not included on the claim as the referring provider.
A primary care provider is responsible for ordering the following services for the restricted recipient:
- Transportation services; if the recipient is restricted to a primary physician or primary clinic, only the primary physician or primary clinic will be allowed to order transportation services;
- Laboratory services;
- DME services; if the recipient also is restricted to a primary DME dealer, that provider will be the only allowed dispenser of DME services; and
- Pharmacy services; if the recipient also is restricted to a primary pharmacy, that provider will be the only allowed dispenser of pharmacy services.
It is the responsibility of the pharmacy and provider to confirm that the member’s restricted provider is aware of and has approved any/all prescriptions written for the member by alternative providers. Once the pharmacy has received this confirmation from the restricted provider, they can proceed with the updated billing requirements outlined in the NYS Medicaid General Billing Guidelines, pg 15.
Providers with questions regarding the submission of claims should contact eMedNY Provider Services at (800) 343-9000 or refer to the provider manuals located on the eMedNY homepage.