PM 20-05-05: Reevaluating the Restriction

WAG 20-05-05.

HFS reevaluates the client's medical usage after 4 full quarters to see if the use is still excessive. The reevaluation has to be done within 18 months of the start of the restriction. The restriction is ended if the medical use is no longer excessive.

If medical use is still high, the restriction is continued for an additional 8 full quarters. If medical usage is no longer excessive after the end of the additional period, the restriction is ended.

When it is necessary to determine if medical services were needed, HFS will obtain a copy of the client's medical record from the primary care provider. A physician and/or pharmacist reviews the record to decide if the care was necessary. If the services were needed, the restriction is ended. When a restriction ends, HFS sends notices to the client and provider telling them the restriction has ended. The restriction ends with the next regular MediPlan Card.

If DPA's review decides the medical care was unneeded, the restriction continues for another 8 full quarters. HFS notifies the client in writing that the restriction is continuing. HFS may choose a different primary provider. Another review will be done after 8 full quarters.