The Restricted Recipient Program identifies suspected cases of abuse of health services or prescription drugs by members.
After assessment, restrictions may be imposed on members. Case management services will be provided to achieve coordination of quality health care services and meet individual member’s healthcare needs in a cost effective manner.
Note: For enrollees on Minnesota Health Care Programs (MHCP), including Medica Choice Care, Medica MinnesotaCare, Medica DUAL Solutions, and Medica AccessAbility Solution, there are additional program requirements as outlined in this document.
- Prescription monitoring: All controlled substance prescriptions for Restricted Recipient members must be written or approved by their selected primary care physician and filled at a designated participating pharmacy.
- Education: Members are informed of the importance of continuity of care.
- Case management services are provided to ensure that the member is maintaining appropriate pharmacy and physician utilization patterns.
For Minnesota Health Care Programs products:
- The program follows the standards set in Minnesota Rules.
- All restricted recipients have designated providers that must provide all services, including a primary care provider, clinic, hospital (including emergency room), and pharmacy.
- The designated primary care provider manages referrals to non-designated providers. Medica will inform providers if they are a designated provider.
Criteria used to identify candidates
Program candidates include:
- Members receiving prescriptions for controlled substances (Schedule I through V) from multiple physicians and/or dentists.
- Members repeatedly utilizing emergency department or urgent care services resulting in obtaining prescriptions for controlled substances.
- Members obtaining overlapping controlled substance prescriptions from one or more physicians.
- Minnesota Health Care Programs members who have abused health care services as described in the Minnesota Rules Part 9505.2165.
In addition, Minnesota Health Care Programs (MHCP) members can be restricted by DHS or another health plan. MHCP members under restriction who change plans will remain under restriction with the new MHCP plan until they have satisfied the time period of the restriction and meet criteria for discharge.
Program management
- A medical director and a case manager work closely together to identify potential members. After identification, medical and pharmacy claim histories are reviewed. Any member with appropriate medical explanations for the criteria listed above are excluded from the program.
- Once identified, the member is contacted by a case manager to assist in coordinating care and services for the member.
- Medica’s case manager contacts the member’s designated primary care provider to provide education about the program and to assist in coordinating care and services for the member.
- The designated primary care provider provides or coordinates all care and services for the member.
- The designated primary care provider authorizes all controlled substance prescriptions for the member.
- For Minnesota Health Care Program enrollees, the designated primary care provider reviews the necessity of care from non-designated providers and authorizes referrals as needed. Medica referral guidelines are in the document titled “Medica Restricted Recipient Referral Guidelines”. The referral guidelines for the Restricted Recipient program are different than those in place for Medica’s care system products. If your patient needs ongoing care from a specialist, consider a standing referral or contact Care Management to discuss arranging to have the specialist added as a designated provider.
For Minnesota Health Care Programs enrollees, check MN-ITS before providing care. If an enrollee is restricted, your claim will not be paid unless you are one of the designated providers or you have received a referral from the member’s designated primary care provider. Claims will be denied as member liability.
For more information about the Medica Restricted Recipient Program, call Care Management toll-free at 1-800-458-5512, provider option 1, option 4.
Prior Authorization may also be required for Par Services.
For the most current listing, download the Medica Prior Authorization list or call the Medica Prior Authorization number at 1-800-247-0153, options 1, option 4, and option 4.
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