Welcome, Brokers!

Fidelis Care would like to inform providers of updated requirements with the NYS Recipient Restriction Program. The goal of the Recipient Restriction Program (RRP) is to coordinate medical and/or pharmacy services and improve the quality of care for Medicaid recipients. Coordination of care reduces the potential over-utilization of health care services, prevents abusive or fraudulent behavior, and protects Medicaid recipients’ health and safety.

As of February 24, 2025, a restricted recipient must comply with the Recipient Restriction Program. If restricted to a pharmacy, the restricted recipient will be required to fill prescriptions at their designated pharmacy. Claims will not pay if the restricted recipient attempts to fill their prescriptions at a different pharmacy. Some exceptions may apply in emergency situations.

Also at this time, the prescriber restriction edits will be fully operational. It is important to remember that the primary health care provider, whether a physician, hospital, provider group or clinic, is responsible for the provision of most health care services for the restricted NYS Medicaid member. Prior to providing services at each visit, the provider must verify the member’s current eligibility with Fidelis Care. Restricted recipients are clearly identified (as an ‘RR’) when checking member eligibility using Provider Access Online. Claims submitted for a restricted NYS Medicaid member will be denied if the information of their restricted primary care provider is not included on the claim as the referring provider.

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. 

If a prescription is not written by the restricted member’s assigned PCP, the pharmacy that fills prescriptions for the restricted member is required to coordinate with the assigned PCP to safely manage the delivery of medications.

• If the prescriptions were written as part of an emergency department visit and

the PCP is unavailable (i.e. after hours), the pharmacy is responsible for using professional judgement in filling prescriptions without regard to restriction requirements to verify the prescriptions.

• The pharmacy is responsible for contacting the PCP the next business day regarding the prescriptions obtained by the recipient.

Additional information regarding the RRP, including referrals, billing, and how to change a provider, can be found on the Office of the Medicaid Inspector General’s (OMIG) website at: https://omig.ny.gov/information-resources/about-recipient-restriction-program-rrp

For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.