jagomart
digital resources
picture1_Restriction Exception Codes


 142x       Filetype PDF       File size 0.47 MB       Source: www.health.ny.gov


File: Restriction Exception Codes
guide to restriction exception re codes and health home services re code re code description compatible with health policy notes home services rrp podiatry 02 these are codes to restrict ...

icon picture PDF Filetype PDF | Posted on 17 Jan 2023 | 2 years ago
Partial capture of text on file.
                                                                  GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES 
               RE CODE                                        RE CODE DESCRIPTION                                                   COMPATIBLE WITH HEALTH                                                                                                                   POLICY NOTES 
                                                                                                                                               HOME SERVICES 
                                       RRP Podiatry                                                                                                                                         
                     02                These are codes to restrict recipient to specific                                                                  YES                               
                                                                                                                                                   (See notes)                              
                                       podiatric providers.                                                                                                                                 
                                       RRP Dental                                                                                                                                           
                     03                These are codes to restrict recipient to specific                                                                  YES                               
                                       dental providers.                                                                                           (See notes)                              
                                                                                                                                                                                            
                                       RRP Durable Medical Equipment                                                                                                                        
                                                                                                                                                          YES                               
                     04                                                                                                                                                                     
                                       These are codes to restrict recipient to specific                                                           (See notes)                              
                                       durable medical equipment providers.                                                                                                                 
                                       RRP Pharmacy                                                                                                                                         
                                                                                                                                                          YES                               
                     05                These are codes to restrict recipient to specific                                                           (See notes)                              
                                       pharmacy providers.                                                                                                                                  
                                       RRP Physician                                                                                                                                        
                     06                                                                                                                                   YES                               
                                       These are codes to restrict recipient to specific                                                           (See notes)                               Individuals can be in a Restricted Recipient Program (RRP) and enrolled in Health Home, but the Care 
                                       physicians. 
                                       RRP Clinic                                                                                                                                            Manager should work with the recipient and contact their Managed Care Plan, if applicable, to ensure 
                     08                These are codes to restrict recipient to specific                                                                  YES                                compliance with any restrictions. 
                                       clinics.                                                                                                    (See notes) 
                                       RRP In-Patient Hospital                                                                  
                                                                                                                                                          YES 
                     09                These are codes to restrict recipient to specific                                                           (See notes) 
                                       hospitals for inpatient services. 
                                       RRP Dental Clinic                                                                                                  YES 
                     10                These are codes to restrict recipient to specific                                                           (See notes) 
                                       dental clinics. 
                                       RRP Physician Group                                                                                                YES 
                     11                These are codes to restrict recipient to specific                                                           (See notes) 
                                       physician groups. 
                                       RRP Physician Assistant/Nurse Practitioner                                               
                     12                                                                                                                                   YES 
                                       These are codes to restrict recipient to specific                                                           (See notes) 
                                       PA/NP providers. 
                                       RRP Alternative Pharmacy                                                                 
                                                                                                                                                          YES 
                     13                These are codes to restrict recipient to specific                                                           (See notes) 
                                       alternative pharmacy providers. 
         4/29/2022                                                                                                                                                                                                                                                                                                                                               Page 1 
                                     GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES 
         RE CODE                  RE CODE DESCRIPTION                    COMPATIBLE WITH HEALTH                                                     POLICY NOTES 
                                                                               HOME SERVICES 
                                                                                                        
                      Enrollee in Special Needs MC Plan (HIV SNP)                                       
            20                                                                       YES                
                                                                                 (See notes)            
                      This code is used to identify enrollees in Special                                
                      Needs Plans.                                                                      
                                                                                                        Like mainstream plans, recipients can be members of HIV SNP and enrolled in a Health Home program. 
                      Enrollee in Special Needs MC Plan (HIV SNP)      
            21                                                                       YES 
                      This code is used to identify enrollees in Special         (See notes) 
                      Needs Plans. 
                                                                                                        
                      OMH Children's Waiver                                                             
                                                                                                        Children that received services through this previous waiver have been transitioned to the new Children's 
            23        This code is used to identify recipients in the                NO                 Waiver with Health Home Care Management or Care Management through an Independent Entity. The 
                      OMH Home & Community Based Services                        (See notes)            use of this RRE Code has ended effective 3/31/2019. 
                      (HCBS) waiver for seriously emotionally 
                      disturbed (SED) children. 
                      OPWDD - Sub-Chapter A Exception                                                   
                                                                       
            25                                                                       NO 
                      This  code is for individuals receiving OPWDD for 
                      a limited period of time with no local shares. 
                                                                                                        
                      LTHHCP - Long Term Home Health Care                                               
                      Program (Lombardi Waiver)                                                         
                                                                                                        Individuals receiving services through this waiver can either be enrolled in a Health Home or in the waiver, 
            30        Code used for individuals authorized for long                  NO                 but cannot be in both as each provides care management services. Care managers should work with 
                      term care services who are eligible for nursing            (See notes)            individuals to determine which service best meets their needs. 
                      home level of care and are residing in the 
                      community. Services provided through a 
                      certified LTHHCP provider. 
                                                                                                        Children receiving OMH TCM services are being transitioned and adults receiving HIV COBRA, OMH TCM and 
                      Case Management Program; Medicaid Service                                         OPWDD care management have transitioned into Health Homes. Individuals receiving EI TCM services will 
                      Coordination/Case Management Program                           YES                transition to Health Home enrollment at a later date. First Time Mothers/Newborns (NFP Targeted Case 
            35        (Medicaid OMH, COBRA, AI TCM, OPWDD)                       (See notes)            Management) will not transition and can not be enrolled in the Health Home program while enrolled in 
                                                                                                        NFP. NFP Care Managers should refer individuals to the Health Home program upon disenrollment, if 
                      Comprehensive case management program.                                            appropriate . 
     4/29/2022                                                                                                                                                                                     Page 2 
                                         GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES 
          RE CODE                     RE CODE DESCRIPTION                         COMPATIBLE WITH HEALTH                                                              POLICY NOTES 
                                                                                        HOME SERVICES 
                        ICF/DD Res                                                                                   
                                                                                                NO                   Individuals receiving services through this waiver can either be enrolled in a Health Home or in the waiver, 
             38                                                                            (See notes)               but cannot be in both as each provides care management services. Care managers should work with 
                        Recipient is a resident of an  ICF-DD  Facility.                                             individuals to determine which service best meets their needs. 
                        Aid Continuing                                                                               
                                                                                                                     
             39                                                                                YES                   The care managers must work within the individuals established UT. Limitations on services may apply. 
                        Recipient is subject to Utilization Threshold (UT)                 (See notes) 
                        and exempt from copay. 
                        HCBS at Home Non-Intensive Residential                                                       
                        Habilitation                                                                                 At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish 
                        Recipient is in a HCBS Non-Intensive AHRH to                            NO                   to receive care management through a Health Home they must dis-enroll from the waiver. Health Home care 
             44         better serve  consumers in their own homes and                     (See notes)               managers and OPWDD Medicaid Service Coordinator (MSC) managers should work with individuals to 
                        reduce demand for more costly residential                                                    determine whether the waiver or Health Homes can best meet their needs. 
                        placement. 
                        HCBS at Home Intensive Residential                                                           
                        Habilitation                                                                                 
                                                                                                                     
                                                                                                NO                   
             45         Recipient is in a HCBS IBS to better serve                         (See notes)               
                        consumers in their own homes and reduce                                                      
                        demand for more costly residential  placement.                                               At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish 
                                                                                                                     to receive care management through a Health Home they must dis-enroll from the waiver. Health Home care 
                                                                                                                     managers and OPWDD Medicaid Service Coordinator (MSC) managers should work with individuals to 
                        OPWDD Home & Community Based Services                                                        determine whether the waiver or Health Homes can best meet their needs. 
                        Waiver - HCB (Pure Waiver)                                              NO 
             46                                                                            (See notes) 
                        Identifies a recipient in home & community 
                        based services waiver program (HCBS). 
      4/29/2022                                                                                                                                                                                                           Page 3 
                                    GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES 
         RE CODE                  RE CODE DESCRIPTION                   COMPATIBLE WITH HEALTH                                                    POLICY NOTES 
                                                                              HOME SERVICES 
                                                                                                       
                     OPWDD HCBS Community Habilitation Phase 2                                         
                                                                                    NO                 
            47       Identifies a recipient in home & community                 (See notes)            
                     based services waiver supervised CR or                                            
                                                                                                       
                     supervised IRA.                                                                   
                                                                                                       At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish 
                     OPWDD HCBS Supportive IRAs and CRs                                                to receive care management through a Health Home they must dis-enroll from the waiver. Health Home care 
            48                                                                      NO                 managers and OPWDD Medicaid Service Coordinator (MSC) managers should work with individuals to 
                     Identifies a recipient  in home & community                (See notes)            determine whether the waiver or Health Homes can best meet their needs. 
                     based services waiver supportive IRA & CR. 
                     OPWDD HCBS Supervised IRA                        
                                                                                    NO 
            49       Identifies a recipient  in home & community                (See notes) 
                     based services waiver supervised IRA & CR. 
                                                                                                       
                     MCC Pharmacy                                                                      Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care 
            55       An HR recipient enrolled in the MCCP and                       YES                manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any 
                     receiving pharmacy services from the primary                                      restrictions. 
                     pharmacy. 
                                                                                                       
                     MCC Physician                                                                     
                                                                                                       
                                                                                                       
                     An HR recipient enrolled in the MCCP and                                          Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care 
            56       assigned to a primary physician or a preferred                 YES                manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any 
                     provider. Non-emergent transportation must be                                     restrictions. 
                     ordered by a primary provider only. Ancillary 
                     services (pharmacy,  DME  &  lab)  must  be 
                     ordered by primary or referred provider. 
                                                                                                       
                     MCC Clinic                                                                        
                                                                                                       
                                                                                                       Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care 
                     An HR recipient enrolled in the MCCP and                       YES 
            58       assigned to a primary clinic where s/he must               (See notes)            manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any 
                     receive care or be referred for care. Ancillary                                   restrictions. 
                     services (pharmacy, DME & lab) must be 
                     ordered by primary only. 
     4/29/2022                                                                                                                                                                                  Page 4 
The words contained in this file might help you see if this file matches what you are looking for:

...Guide to restriction exception re codes and health home services code description compatible with policy notes rrp podiatry these are restrict recipient specific yes see podiatric providers dental durable medical equipment pharmacy physician individuals can be in a restricted program enrolled but the care physicians clinic manager should work contact their managed plan if applicable ensure compliance any restrictions clinics patient hospital hospitals for inpatient group groups assistant nurse practitioner pa np alternative page enrollee special needs mc hiv snp this is used identify enrollees plans like mainstream recipients members of omh children s waiver that received through previous have been transitioned new no...

no reviews yet
Please Login to review.