CONCLUSIONES

Members determined to be abusing medical coverage may be restricted to one primary care physician (PCP), one pharmacy, and one hospital (for non-emergency services). The initial Lock In period for all newly identified members is twenty-four months. A member who has completed the initial twenty-four month period and who is subsequently found to have misused benefits for a second time will be placed in extended Lock In with no termination date. Immediate placement in the Lock-In Program can be initiated if a member is convicted of fraud or abuse. Members placed into the Lock-In Program will receive a certified Initial Placement Letter that includes:

 The reasons the member was found to have misused medical or pharmacy benefits  Names and locations of assigned providers (PCP, Pharmacy and Hospital)

 Notification of the opportunity to change the providers within 10 days after receipt of the letter  The member will be held liable for medical bills incurred if the member accesses non-emergent services

from a non-lock-in provider.

 Notification of appeal and fair hearing rights

In the assignment of providers, Amerigroup will consider geographic location and reasonable travel time, claims evidence that the member has an established provider(s), and any Lock Out restrictions.

If the member accesses non-emergent services from an unassigned Lock-In provider, the member will be held responsible for those medical bills. The member must always coordinate services through the assigned providers.

Members who were placed in Lock-In by the Kansas Department of Health and Environment, and for whom Amerigroup is honoring the Lock-In status, an extension of the appeal rights for placement into Lock-In will not be extended.

Assignment of a Member in the Lock-In Program

Lock in providers will be notified via written communication of those members who have been assigned to them.

The assigned or selected PCP will be notified in writing of the member’s placement into the Lock-In program. The notification will include:

 A list of the member’s assigned providers

 General information regarding the Lock-In process and program

 A 6 month drug profile for the PCP’s or prescribers to review with the member

 A questionnaire to be completed by the PCP designed to collect information supporting the reason for Lock-In

 A Lock-In Referral Form

Lock-in providers are never required to provide services or medications not supported by medical necessity. The member is expected to actively share in the lock-in responsibility by only receiving health care, prescription medications and hospital outpatient services from the assigned lock-in providers. If the lock-in member fails to follow medical advice, the lock-in providers are not required to provide requested referrals or treatment.

The lock-in physician is the primary prescribing physician. Narcotics and controlled substances should only be

prescribed by the lock-in physician or approved by his or her specific referral .

If the assigned provider is dissatisfied with the decision and would like to request a different provider, pharmacy or hospital for non-emergent services, the provider can call Member Services at 1-800-600-4441.

The assigned Lock-In pharmacy will be the only pharmacy authorized to fill prescriptions for the member. The

pharmacy should assist in the member’s care by reviewing the prescription history and contacting the prescriber when necessary to ensure coordinated care.

If the lock-in physician allows prescription prescribing privileges to a referred-to physician, the lock-in member will require a copy of the referral to present to the Lock-In pharmacy. Lock-In referrals can be written for one date or subsequent dates, but should not be valid for more than a 30 day period. This practice keeps the lock-in physician apprised of all medical care for the member.

If the assigned Lock-In pharmacy does not have medication to fill a prescription, the member will be allowed to have the prescription filled at a pharmacy that has the medication in stock. The Lock-In pharmacy will call the pharmacy that has the medication in stock.

If there is an urgent need to fill a prescription, a pharmacy other than the designated pharmacy will be allowed to dispense up to a seventy-two (72) hour emergency supply of covered medication. Prior authorization is not required. The member will be allowed to obtain the remainder of the prescription during the next business day.

The member will be restricted to the use of one hospital for nonemergency services. When a Lock-In member

uses the emergency room and triage reveals the symptoms are non-emergent, the lock-in hospital can decide whether to treat or refer the member to the lock-in physician. It is recommended that the lock-in physician instruct the emergency room staff regarding how to handle non-emergent situations for the member. Referral Requirements

The assigned PCP must provide a referral for specialty services prior to the service being rendered. If the lock-in member fails to follow medical advice, the lock-in providers are not required to provide requested referrals or treatment. The lock-in physician is the primary prescribing physician. Narcotics and controlled substances should only be prescribed by the lock-in physician or approved by his or her specific referral. If the lock-in physician allows prescription prescribing privileges to a referred-to physician, the lock-in member will require a copy of the referral to present to the Lock-In pharmacy.

Suspected Fraud or Abuse

Call the Provider Services Unit at 1-800-454-3730 or provide written notification should you suspect any incidents of fraud or abuse. Send written documentation to:

Amerigroup Kansas, Inc.

9225 Indian Creek Parkway, Building 32 Overland Park, KS 66210

Attn: Lock – In Program

HOW WE SUPPORT OUR MEMBERS

9.

9.1 Amerigroup as the Member Health Home

The Kansas Department of Health and Environment (KDHE), Amerigroup and the other participating Managed Care Organizations (MCOs) in KanCare are working together to develop an innovative health home program to be announced and implemented beginning in 2014. We will provide you with additional information as the programs are developed.