Recipient Restriction Program (RRP)

The Recipient Restriction Program (RRP) is a New York State Medicaid program designed to coordinate medical services for Medicaid members that have been identified as exhibiting abusive or fraudulent behavior. The program helps reduce unnecessary costs to the Medicaid program, avoid misuse of services and supports appropriate utilization of healthcare resources.

When a Member May Be Placed in the RRP

A member may be placed in the RRP when a review identifies a pattern of:

• Duplicative healthcare services
• Excessive or duplicative use of drugs, supplies or appliances
• Contraindicated or conflicting care, medications, or supplies
• Other patterns indicating inappropriate use of Medicaid benefits 

Under the program, a member may be assigned to a specific:

• Primary Care Provider (PCP)
• Primary Care Clinic
• Pharmacy
• Inpatient hospital
• Other designated provider, depending on the restriction type

If Your Patient Has an RRP Designation

If you are assigned as a member’s designated provider under the RRP, you play an important role in coordinating the member’s care. Emergency services are not subject to RRP restrictions.

PCP and Primary Care Clinic Responsibilities:

• Serve as the primary point of contact for non-emergency medical care. 
• Provide care directly or coordinate care through referrals when specialty services are needed. 
• Manage referrals for non-emergency specialty services, diagnostic testing, transportation, and other covered services. 
• Instruct any specialists or other providers with whom you are coordinating care to list you as the referring provider on the submitted claim. Claims may be denied if you are not identified as the referring provider.

Pharmacy Responsibilities:

• Help coordinate and manage medication services. 
• Verify referrals and coordinate with the assigned PCP when prescriptions are written by another provider. 

Provider Notifications:

Providers assigned to a restricted member will receive written notification that includes:

• Restriction effective date
• Scope of restriction
• Restriction type and duration (the initial restriction period is two years)
• Assigned providers
• Provider responsibilities related to care coordination and referrals

Questions?

You can find more information on the NYS Office of the Medicaid Inspector General website.

If you have questions about a member’s RRP designation, provider responsibilities, referrals, or care coordination requirements, please contact:

VNS Health Provider Services
1-866-783-0222
Monday-Friday, 8:00 a.m.-5:00 p.m.

Please have the member’s ID number available when calling.