The goal of the Recipient Restriction Program (RRP) is to coordinate medical services and improve quality of care for Medicaid recipients. Coordination of care reduces the potential over-utilization of health care services and prevents abusive or fraudulent behavior.
The State Medical Review Team (SMRT), within the RRP, performs comprehensive utilization reviews of a recipient’s Medicaid services. The RRP may restrict the recipient to care provided by, or referred by, a Primary Care Provider, Inpatient Hospital, and/or Primary Pharmacy. A restriction is implemented if it is found that the recipient has received duplicative, excessive, contraindicated, or conflicting health care services, drugs, or supplies, or if a recipient commits fraudulent acts with their benefit card (i.e., forged prescriptions, card loaning, doctor shopping).
Medicaid Managed Care Plan recipients are also subject to the Recipient Restriction Program. The Plan is required to conduct reviews of Medicaid recipients and restrict recipients to care provided by, or referred by, a Primary Care Provider if it is found that the recipient has received duplicative, excessive, contraindicated, or conflicting health care services, or committed fraudulent acts with their benefit card.
For questions concerning the Recipient Restriction Program, please call 518-474-6866 or email [email protected].