Information for Providers in the Recipient Restriction Program (RRP)

Information

The assigned primary care provider or primary clinic is the ‘gate keeper’ for a restricted recipient. You are responsible for providing direct medical care or coordinating care through referral to another medical provider for specialty services. The assigned primary care provider is also responsible for ordering all non-emergency transportation for the assigned restricted recipient. 

A referral will be needed from the assigned primary care provider for any non-emergency medical services when a specialist is required. Claims submitted for a restricted recipient will be denied if the assigned primary care provider's information is not included on the claim as the referring provider. 

A medication can be prescribed by a specialist and the claim will process when submitted by the pharmacy after entering the assigned primary care providers identification number on the claim. A primary pharmacy is required to coordinate with the assigned primary care provider to safely manage the delivery of medications, including verifying referrals if prescriptions were not written by the assigned primary care provider. Instructions for entering the referring provider ID are below.

If you have any questions regarding the submission of claims, please contact eMedNY Provider Services at (800) 343-9000 or refer to the provider manuals located at https://www.emedny.org, or the RRP Help line at (518) 474-6866 or email: [email protected].

BILLING A REFERRAL FOR A RESTRICTED RECIPIENT

Pharmacy services for Managed Medicaid recipients are billed through NYRx, the Medicaid Pharmacy Program. Medical claims for restricted Medicaid Managed Care recipients should follow guidelines established by the members Managed Care plan. Proper billing procedures for Fee-For Service recipients and the Medicaid Pharmacy Program (NYRx) for restricted recipients are explained below. 

FOR MEDICAL CLAIMS:

When providing services to a member who is restricted to a primary physician or facility, the NPI of the referring professional must be entered. If a member is restricted to a facility, the NPI of the facility’s referring professional must be entered. The ID of the facility cannot be used.

For additional information, visit: https://www.emedny.org/ProviderManuals/AllProviders/General_Billing_Guidelines_Professional.pdf

Paper claims submissions field location process:

Identification Number [Ordering/Referring Provider] [Field 19C] 837P Ref: Loop 2310A NM109
Source: New York State Provider Manual


Electronic claims submissions field process:

Page #Loop IDReferenceNameCodesLengthComments
2102010EANM101Entity Identifier CodeDN2NYDOH will interpret this as the Referring Provider’s Information
2922110CEB01Eligibility or Benefit InformationN1When EB01=N, the patient has provider restrictions for the service type identified in EB03. The provider the patient is restricted to is reported in Loop 2120C.
3302120CNM101Entity Identifier CodeP32When NM101=P3, the entity being identified is the provider the patient is restricted to for the service type reported in EB03.
3332120CNM108Identification Code QualifierXX2NYSDOH will send “XX” when identifying a Restricted Provider.

For additional information, please refer to the NYS Medicaid Companion Guide V 4.0

FOR PHARMACY CLAIMS:

When filling prescriptions/orders for a member who is restricted to an assigned primary care provider (physician, clinic, podiatrist, or dentist) and the assigned primary care provider is the prescribing/ordering provider, the NPI of this provider must be entered in the ordering/prescribing field. 

If the restricted member was referred by the assigned primary care provider to another provider and the referred-to provider is the prescribing/ordering provider, the pharmacy provider must enter the referred-to provider’s NPI in the ordering/prescribing field. The pharmacy must verify the referral with the assigned primary care provider and enter the primary’s NPI as the referring/primary care provider.

Paper claims submissions field process:

Other Referring/Ordering Provider ID/Liscense Number (Field 11A) Prescriptions for Restricted Members - If a restricted member was referred by their primary provider to another provider and this provider is the prescriber/orderer, enter the NPI of the member's primary care provider.  Name [Other Referring/Ordering Provider] (Field 11B) - Enter the name of the member's primary provider, if an NPI has been entered in field 11A.
Source: New York State Provider Manual

For additional information, visit: https://www.emedny.org/ProviderManuals/Pharmacy/PDFS/Pharmacy_Billing_Guidelines.pdf

Electronic claims submissions field process:

Primary Care Provider IDEnter the NPI of the primary care provider the member is restricted to421-DL
Primary Care Provider ID QualifierEnter 01 (NPI)468-2E

For additional information, visit: https://www.emedny.org/ProviderManuals/Pharmacy/ProDUR-D.0-ECCA_Provider_Manual/Pro%20DUR%20ECCA%20Provider%20Manual%20(D.0).pdf

ADDITIONAL INFORMATION AND RESOURCES

For NYC recipient provider changes, a provider can initiate the change by completing the MAP-3046a form and send to NYC Human Resources Administration: MAP-3046a

For transportation approvals/inquiries:

Frequently Asked Questions (FAQs)