PURPOSE: This rule establishes the regulatory basis for implementation of a method to limit or restrict the use of the recipient’s Medicaid identification card to designated providers of medical services.

1. (1) Definitions which shall apply in the administration of this program.

   1. (A) Misutilization of medical services is defined as the act of seeking or obtaining medical services, or both, from a number of like providers and in quantities which exceed the levels that are considered medically necessary by current medical practices, standards and policies of the Missouri Title XIX Medicaid Program.
   2. (B) Lock-in is defined as the method to limit or restrict the use of the recipient’s Medicaid identification (ID) card to a designated provider(s) only. When one (1) of the designated providers is a physician, this provider is the primary-care physician and is responsible for providing or directing, or both, the recipient’s medical care and for making any necessary referrals to other providers as medically indicated.
   3. (C) The Division of Medical Services, Surveillance and Utilization Review System Unit will review all suspect or potential cases of lock-in. The Surveillance and Utilization Review System Unit professional staff will initiate lock-in procedures after utilization review of documented services indicate misutilization of Title XIX services, benefits, or both.

2. (2) The lock-in or limitation is for one (1) person and the fiscal agent audit is for that person’s individual Medicaid ID number. Payment to any other provider(s) with the provider type of the designated provider is limited to—

   1. (A) Documented emergencies; and
   2. (B) Referral from the designated provider, with designated provider’s name or provider’s number on all claims submitted by the other provider(s) to show designated provider as the referring physician or provider.
3. (3) In cases where treatment or service by another provider of the same type as the designated provider is needed is not an emergency and the designated provider is not available to render service to the recipient, the recipient may obtain an authorization from the individual’s Division of Family Services local office which allows the recipient to obtain the needed service from a different provider. The form is titled Medical Referral Form of Restricted Recipient and is numbered MSS- S/UR-118. This form is also available from the state office Division of Medical Services, Surveillance and Utilization Review System Unit, P.O. Box 6500, Jefferson City, MO 65102-6500. The form must be attached to the different provider’s claim for reimbursement.
4. (4) Change of the designated provider may be requested by the recipient during a period of lock-in. The recipient must contact his/her Division of Family Services local office and request the change of provider by completing the Recipient Lock-In Form Authorization for Medical Services. The change of approved authorized provider(s) will be effective the first day of the month following the receipt of the completed Authorization for Medical Services Form. In the event the change of authorized provider(s) cannot be reflected on the recipient’s Medicaid ID card on the first day of the month following the receipt of the Authorization for Medical Services Form, the recipient’s Division of Family Services local office may replace the Medicaid ID card with a corrected income maintenance letter of eligibility showing the proper listing of designated provider. A copy of the income maintenance letter must be forwarded to the Division of Medical Services Surveillance and Utilization Review System Unit for case documentation. No more than one (1) provider-type change may be allowed in a three (3)-month period. Exceptions to the previously mentioned may be approved if documentation is presented for just cause of additional authorized provider changes within the three (3)-month period. This documentation must be submitted by the recipient’s caseworker in writing for review and approval by the Division of Medical Services Surveillance and Utilization Review System Unit professional staff.

5. (5) Lock-In Provider Types.

   1. (A) Medical—physician.
   2. (B) Pharmacy.
   3. (C) Dental.
   4. (D) Optometrist.
   5. (E) Optical company.
   6. (F) Ambulance.
   7. (G) Durable medical equipment.
   8. (H) Institutional—inpatient—outpatient— emergency room facility.
   9. (I) Audiology.
   10. (J) Home health.
   11. (K) Podiatry.
   12. (L) Independent clinic
6. (6) Recipients have free choice of providers who are participants in the Missouri Medicaid program. Professional practitioners have the right to accept or refuse recipients for treatment. Both the provider and recipient must be agreeable to the lock-in relationship. If the recipient does not cooperate in designating a lock-in provider, the Division of Medical Services or local Division of Family Services office may arrange for a provider after documenting the recipient’s lack of cooperation in designating a provider. The medical ID card may be held only as a mechanism to get the recipient to the Division of Family Services office to discuss or select a lock-in provider.
7. (7) The recipient selected for lock-in has the right to the fair hearing procedures as offered under applicable state law and federal regulations.
8. (8) The lock-in period will be for a minimum of twelve (12) months and a maximum of twenty-four (24) months. Not sooner than twelve (12) months but no longer than twenty-four (24) months after a recipient has been placed on lock-in, the Surveillance and Utilization Review System Unit professional staff will review the case and continue the recipient on lock-in if review of documented services indicates continuing misutilization of Title XIX services, benefits, or both. The lock-in period will again be for a minimum of twelve (12) months and a maximum of twenty-four (24) months before another review is conducted, after which lock-in may again be renewed. Recipients who have initially been placed on the lock-in program prior to December 1, 1985 will continue to be subject to twelve (12)-month reviews. The recipient has the right to the fair hearing procedures as offered under applicable state law and federal regulations if s/he is continued on lock-in after a review. The effective date for the start of lock-in should be the same for the medical ID card and the audit implementation of the fiscal agency by the Surveillance and Utilization Review System Unit. A form processed by electronic data processing and forwarded to the fiscal agency will give the effective date of lock-in. If a case is closed during a twelve (12)-month period, the lock-in restriction would automatically still be in effect at the fiscal agent unless the medical ID number was changed. The lock-in period should be continued a full twelve (12) months. A new Authorization of Medical Services Form should be submitted on any change of provider. The Surveillance and Utilization Review System Unit should also be advised of any name or Medicaid ID number changes instigated in behalf of lock-in recipients.

9. (9) If Missouri Medicaid recipients are identified as misutilizing the Title XIX Medicaid Program in the following areas, but not limited to, lock-in proceedings, referral to the Division of Investigation, or both, will be implemented:

   1. (A) Lending Medicaid ID card to noneligible persons;
   2. (B) Submitting forged documents to providers for medical benefits or services;
   3. (C) Seeking excessive or unnecessary medical care as defined in subsection (1)(A) of this rule, that is, drugs, office visits, eyeglasses, dentures, etc.;
   4. (D) Utilizing multiple medical providers; or
   5. (E) Refusing to submit to or failing to have predicted urine or blood levels following testing for opioid or opioid-like controlled substances covered by Missouri Medicaid while engaged in a pain or substance abuse treatment regimen. AUTHORITY: section 208.201, RSMo 2000.* This rule was previously filed as 13 CSR 40- 81.200. Emergency rule filed July 13, 1981, effective Aug. 1, 1981, expired Oct. 10, 1981. Original rule filed July 13, 1981, effective Oct. 11, 1981. Amended: Filed Sept. 4, 1985, effective Dec. 1, 1985. Amended: Filed Nov. 2, 1988, effective Jan. 13, 1989. Amended: Filed Aug. 1, 2003, effective Feb. 29, 2004.

*Original authority: 208.201, RSMo 1987.