Restriction Program

Pain Management

Restriction

Medicaid Restriction Program

1-800-662-9651, #900
(801)538-9045

The Restriction Program promotes Medicaid recipients' appropriate use of medical services by identifying and correcting misuse of services. Recipients may be identified by analysis of medical claims, review of medical records, or referrals from other agencies, providers, or the general public.

Utilization of Medicaid benefits is considered excessive and/or abusive if it meets or exceeds the following measures:

  • Physicians

    • The number of physicians (not including radiologists, pathologists, or assistant surgeons) is 4 to 6 per year; or
    • The number of physicians seen for the same or a similar diagnosis is 4 or more; or
    • Clear indications of duplications of services for the same diagnosis unless it is for a 2nd opinion before intended and necessary surgery.

  • Abuse Potential Drugs

    • Consecutive Abuse: If the average daily dose of abuse potential medications is equal to or greater than 3 per day from more than one prescriber within a 6 month period; or
    • Concurrent abuse: If potential abuse meds are being prescribed at the same time by more than 1 prescriber.

    Note: Any referral from a reliable source where there is documented evidence that forgery has occurred will be grounds for immediate restriction. This includes altered or bogus prescriptions as well.


  • Pharmacy Over Utilization:

    • Prescriptions filled at 3 or more pharmacies when there is evidence of drug abuse or dependence; or
    • Allegations of abuse from a pharmacist or other health professional.
    • In addition to Schedule II, III, and IV drugs, other abuse potential drugs are also counted. (schedule III and IV are habituating rather than addicting).

  • Emergency Room :

    Three or more visits to the ER for non-life threatening / routine medical care that could be treated in a physician's office within a one-year period.

  • Diagnoses:

    Diagnoses, when available, will be considered in the evaluation. Diagnoses of opioid or drug dependence, alcohol abuse, or a miscellany of unrelated diagnoses that would indicate the potential or possibility for drug seeking or doctor hopping will be reviewed.


  • Dental :

    More than 2 dentists, especially when there is no follow up treatment, is a sign of potential abuse.


  • Podiatry :

    More than 2 podiatrists within a year.

If you have a Medicaid client that may benefit from being placed on Restriction, please contact Nancy, Melanie, or Katie at the Medicaid Restriction Department by calling 801-538-9045 or toll free 1-800-662-9651 ext.#900.

Clients who meet the criteria for Restriction will be advised of the reasons for Restriction and assigned a Restriction Primary Care Physician and Restriction Pharmacy. The Primary Care Physician is the only authorized prescriber. Clients will be given the opportunity to provide justification for the medical services that they have received, and instructed on how to appeal Restriction.