OMIG Update

Recipient Restriction Program (RRP) Restriction Edits Restored

Effective February 24, 2025, restriction edits supporting the Recipient Restriction Program (RRP) have been restored.  As a result, a restricted recipient will be required to obtain all of their care, directly or by referral, from their assigned providers.

• An assigned Primary Care Provider (PCP) is responsible for providing direct medical care or coordinating care through referral to another medical provider for specialty services.  The assigned PCP is also responsible for ordering all non-emergency transportation, laboratory, DME, and pharmacy services for the assigned restricted recipient.  A referral will be needed from the assigned PCP for any non-emergency medical services when a specialist is required.  Claims submitted for a restricted recipient will be denied if information for the assigned PCP is not included on the claim as the referring provider.

• A pharmacy filling prescriptions for a restricted member is required to coordinate with the assigned PCP to safely manage the delivery of medications, including verifying referrals if prescriptions were not written by the assigned PCP.  The pharmacy is responsible for using professional judgement in filling prescriptions without regard to restriction requirements if the prescriptions were written as part of an emergency department visit and the assigned PCP is unavailable (i.e., after hours) to verify the prescriptions.  The pharmacy is responsible for contacting the assigned PCP the next business day regarding the prescriptions obtained by the recipient.

• An assigned primary inpatient hospital is responsible for providing all non-emergency inpatient services to the restricted recipient except for services provided pursuant to an authorized referral.

EMERGENCY PHARMACY SITUATIONS:
In the event of an emergency, such as: drug shortages, unexpected pharmacy closures, and/or unexpected travel, see below:

During normal business hours, the recipient can obtain a temporary authorization to fill the prescription at an alternate pharmacy location by contacting:

OMIG (Monday – Friday) (8a – 4p)
518-474-6866 or omig.sm.rrp@omig.ny.gov

The local department of social services (LDSS) - for upstate recipients
https://www.health.ny.gov/health_care/medicaid/ldss.htm

NYC Human Resources Association (HRA) - for NYC recipients
888-692-6116

NY State of Health (NYSoH) - for coverage obtained through the NYSoH
518-457-0761 or hxrestrict@health.ny.gov

During nights and weekends the pharmacy can obtain a prior authorization by contacting: eMedNY call center (Monday – Friday 4p –10p); 
Saturday and Sunday (8:30a – 5:30p)
800-343-9000

Additional Information:

The goal of the RRP is to coordinate medical services and improve quality of care for Medicaid recipients.  Coordination of care reduces the potential over-utilization of health care services and prevents abusive or fraudulent behavior.  A restriction is implemented if it is found that a recipient has received duplicative, excessive, contraindicated, or conflicting health care services, drugs, or supplies, or if a recipient commits fraudulent acts with their benefit card (i.e., forged prescriptions, card loaning, doctor shopping).  The RRP may restrict the recipient to care provided by a PCP, Inpatient Hospital, and/or Primary Pharmacy.

Additional information regarding the Recipient Restriction Program can be found on the OMIG website at: https://omig.ny.gov/information-resources/about-recipient-restriction-program-rrp.