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(Revised 6/1/2010 ML #3219)
Under the Coordinated Services Program (CSP), a review is completed by the Surveillance Utilization Review System (SURS) staff within the Medical Services Division. This review will assist to determine if certain recipients are misutilizing services. When this review is completed, and it is determined that a recipient is misutilizing, the SURS staff contacts the county agency and asks that the recipient choose a provider who will be asked to manage the recipient's health care. The eligibility worker will review the guidelines and policy for the CSP Program with the recipient.
The Coordinated Services Program is more stringent in looking at the recipient's medical needs and in establishing controls to assure that the recipient receives continuity of care while learning acceptable utilization practices. In addition, the recipient may be locked into certain providers who are exempt from PCP, such as psychiatrists, dentists, and pharmacies.
If a coordinated services recipient is required to name a PCP, that provider must be the same as the Coordinated Services Program provider. If the Coordinated Services Provider is one that is not on the Primary Care Provider list, please contact the SURS administrator. The PCP will then be changed to an “exempt” status. However, this does not exempt the recipient from any referral requirements. The recipient will be required to follow the rules outlined within the Coordinated Services Program. All CSP rules supersede the PCCM guidelines.
Recipients on the Coordinated Services Program will remain on it until their status has been changed by recommendation of the department's professional consultants.
The rules for changing a PCP in Coordinated Services Program cases must follow the Coordinated Services Program policy and must be approved by SURS staff. These rules can be located within the General Information for Providers Manual, Coordinated Services Chapter which can be located electronically at: http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/gen-info-providers.pdf
