Coordinated services

1. For purposes of this section: a. "Coordinated services" means the process used to limit a recipient's medical care and treatment to a single physician or other provider to prevent the continued misutilization of services. b. "Coordinated services provider" means a physician, nurse practitioner, physician assistant, or Indian health service or tribal health facility or clinic selected by the coordinated services recipient to provide care and treatment to the recipient. The selected coordinated services provider is subject to approval by the department. c. "Misutilization" means the incorrect, improper, or excessive utilization of medical services which may increase the possibility of adverse effects to a recipient's health or may result in a decrease in the overall quality of care. 2. Coordinated services may be required by the department of a past, current, or future recipient who has misutilized services, including: a. Securing excessive services from more than one provider when there is little or no evidence of a medical need for those services; b. Drug acquisition in excess of medical need resulting from securing prescriptions or drugs from more than one provider; c. Excessive utilization of emergency services when no medical emergency is present; or d. Causing services to be misutilized due to fraud, deception, or direct action, without regard to payer source. 3. The determination to require coordinated services of a recipient is made by the department upon recommendation of medical professionals who have reviewed and identified the services the recipient appears to be misutilizing. 4. The following factors must be considered in determining if coordinated services is to be required: a. The seriousness of the misutilization; b. The historical utilization of the recipient; and c. The availability of a coordinated services physician or provider. 5. If a coordinated services recipient does not select a coordinated services provider within thirty days after qualifying for the program, the department will limit the recipient to only medically necessary medical and pharmacy services. If a coordinated services recipient selects a coordinated services provider after the initial thirty days, the selection will be reviewed by the department to determine if the selected provider is appropriate and to ensure the provider accepts the assignment. A coordinated services recipient may have a coordinated services provider in more than one specialty, such as medical, dental, or pharmacy. 6. Upon a determination to require coordinated services: a. The department shall provide the recipient with written notice of: (1) The decision to require coordinated services; (2) The recipient's right to choose a coordinated services provider, subject to approval by the department and acceptance by the provider; (3) The recipient's responsibility to pay for medical care or services rendered by any provider other than the coordinated services provider; and (4) The recipient's right to appeal the requirement of enrollment into the coordinated services program. b. The appropriate human service zone shall: (1) Obtain the recipient's selection of a coordinated services provider; and (2) Document that selection in the case record. 7. Coordinated services may be required of an individual recipient and may not be imposed on an entire Medicaid or children's health insurance program case. If more than one recipient within a case is misutilizing medical care, each individual recipient must be treated separately. 8. Coordinated services may be required without regard to breaks in eligibility until the department determines coordinated services is discontinued. 9. No Medicaid or children's health insurance program payment may be made for misutilized medical care or services furnished to the coordinated services recipient by any provider other than the recipient's coordinated services physician or provider, except for: a. Medical care rendered in a medical emergency; or b. Medical care rendered by a provider upon referral by the coordinated services physician or provider and approved by the department. 10. A recipient may appeal the decision to require coordinated services in the manner provided by chapter 75-01-03.