Medicaid recipients who inappropriately utilize Medicaid services may be referred to and enrolled in the Restriction Program. This program provides safeguards against inappropriate and excessive use of Medicaid services.

 Patients are identified for enrollment through:

l. Quarterly review of patient profiles to identify exceptional utilization of medical services.
2. Verbal and written reports of inappropriate use of services generated by one or more health care providers. These reports are verified through a review of the patient's claim history by Medicaid staff and medical consultants.
3. Referral from Medicaid staff.

Patients selected for enrollment are informed of the reasons for the issuance of a Restriction Program card, counseled in the appropriate use of health care services, and assisted in selecting a Primary Care Provider and pharmacy. They are issued a Restriction Medicaid Identification Card. For patients in the Restriction Program, Medicaid will only pay claims for services rendered by the providers listed on the card and by providers to whom the patient has been appropriately referred. However, emergency services are not restricted to these providers.

For more information, refer to the Medicaid Member Guide.  There is also a telephone number in the guide for the Restriction Program Manager.