(a)  The Division shall have methods and procedures for the control of recipient overutilization of Medicaid benefits.  These methods and procedures shall include Lock‑In of a recipient, shown to be an overutilizer, to specified providers of health care and services.

(b)  Prior to implementing Lock‑In the following steps shall be taken:

(1)           Recipient's utilization pattern will be documented as inappropriate;

(2)           Recipient will be notified that the State is imposing a Lock‑In procedure;

(3)           Recipient will be offered the opportunity to select a provider;

(4)           In the event the recipient fails to select a provider, a provider will be selected for him by the Division of Medical Assistance;

(5)           Recipient will receive an eligibility card indicating the selected providers.

(c)  Recipient utilization patterns will be reviewed periodically to determine if changes have occurred.  If the utilization pattern has been corrected, the Lock‑In status will be ended; if the utilization pattern remains aberrant, Lock‑In status will be continued.

(d)  Division may Lock‑In a recipient provided:

(1)           The recipient is given notice and an opportunity for a hearing before imposing restriction, pursuant to state statutes governing appeals by public assistance recipients.

(2)           The Division assures that the recipient has reasonable access to Medicaid care and services of adequate quality.


History Note:        Authority G.S. 108A‑25(b); 108A‑64; 108A‑79; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984.