CurrenthennepinhealthPolicy N/A

Restricted Recipient Program

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Describes Hennepin Health's implementation of the State of Minnesota Restricted Recipient Program, including member responsibilities, provider/pharmacy/hospital selection, referral and restriction rules, and how restrictions carry across plan changes; applies to Hennepin Health members placed in the program.

Policy Summary

Payerhennepinhealth

PolicyRestricted Recipient Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMember must choose a primary care provider and obtain PCP referrals before seeing other providers; referrals must be sent to the Restricted Recipient Program within 90 days after the visit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24/36length of restriction period

40 mimax PCP distance

30 daysreturn Provider Selection form

90 daysprovider change restriction window

Program Coverage and Restrictions

Program coverage and restrictions

Coverage and restriction rules while enrolled in the Restricted Recipient Program:

Members retain all health benefits; benefits will not be denied, reduced, or terminated because of program participation.

Members are enrolled in the program for either 24 or 36 months of eligibility; time in the program accumulates across plan changes and coverage lapses (members resume remaining restriction upon re-enrollment).

All health care needs must be coordinated by the member's chosen or assigned primary care provider (PCP).

Referral requirement: Members must obtain a referral from their PCP before seeing other providers or specialists or using non‑PCP hospitals; the PCP must send the referral to the Restricted Recipient Program at Hennepin Health within 90 days after the member sees the other provider.

Provider, hospital and pharmacy restrictions: Members must use the providers, hospital and pharmacy associated with their PCP; if a member obtains services or fills prescriptions at non‑designated providers or pharmacies, claims may be rejected and the member may be responsible for payment.

Consequences for not obtaining referrals: Medical bills for services received without required PCP referral may be the member's responsibility and can extend the member's time in the program (for example, an additional 36 months).

Continuity across plan changes: If a member leaves the health plan and later enrolls in another plan, the member remains in the Restricted Recipient Program and completes the remaining restriction period under the new plan; retroactive coverage is payable only for services received from restricted providers.

Billing and Pharmacy Acceptance

No billing/coding specifics providedmixed

No codes listed

Pharmacy claim acceptance — system rejects charges if prescription filled at non-designated pharmacy

System behaviorIf a member fills a prescription at a pharmacy different from the pharmacy chosen/associated with their assigned primary care provider, the system will not accept the charges and will instruct the pharmacist that the member must use a specific pharmacy.

Member financial responsibilityIf charges are submitted at a non‑designated pharmacy and not accepted by the system, the member may be held responsible for the bill if services were obtained outside program rules.

Association with PCPPharmacy designation is tied to the member's chosen or assigned primary care provider as part of the Restricted Recipient Program rules.

Provider, Referral, and Emergency Guidance

Prior Authorization

PCP referral required; submission within 90 days

The member’s PCP must approve visits to other providers and certain behavioral health services; referrals must be written before the visit and the PCP must send the referral to the Restricted Recipient Program within 90 days after the visit.

PCP must approve all visits to other doctors or medical providers, including certain behavioral health services such as a psychiatrist, clinical nurse specialist or a methadone clinic.
Have your primary care provider write a referral BEFORE you go to the other provider and the referral must state which specialist you will see.
Primary care provider must send the referral to the Restricted Recipient Program at Hennepin Health within 90 days after the visit.

Documentation Required

Emergency and urgent care use guidance

Use the designated hospital emergency room or your designated clinic’s urgent care for emergencies; reserve emergency and urgent care for true emergencies and call 911 or go to the closest hospital for life‑threatening emergencies.

Always use your designated hospital’s emergency room or your designated clinic’s urgent care center for emergency/urgent needs when appropriate.
For life‑threatening emergencies call 911 or go to the closest hospital.
Hospital ERs and urgent care centers should not be used for routine care that can be obtained from the PCP.

Program Definitions

Definition of the Restricted Recipient Program

Program purposeState-created program to help organize a member's medical care by assigning or having the member choose a primary care provider who coordinates care while the member remains in the program.

Benefit protectionMembers do not lose health benefits and benefits will not be denied, reduced, or terminated because of program participation.

Program durationMembers remain in the program for either 24 or 36 months of eligibility; time accumulates and continues across plan changes or coverage gaps.

PCP requirements

Accepted PCP typesPCP must be a family practice, internal medicine, or general practice physician, a nurse practitioner, or a physician assistant.

Distance requirementPCP must be located within 40 miles of the member's home.

Referral approvalThe PCP must approve all visits to other doctors or medical providers (including certain behavioral health services); referrals must be written before the visit and the PCP must send the referral to the Restricted Recipient Program within 90 days after the visit.

Policy Summary

Payerhennepinhealth

PolicyRestricted Recipient Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMember must choose a primary care provider and obtain PCP referrals before seeing other providers; referrals must be sent to the Restricted Recipient Program within 90 days after the visit.

SourceLink

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Restricted Recipient Program

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Program Coverage and Restrictions

Program coverage and restrictions

Coverage and restriction rules while enrolled in the Restricted Recipient Program:

Members retain all health benefits; benefits will not be denied, reduced, or terminated because of program participation.

All health care needs must be coordinated by the member's chosen or assigned primary care provider (PCP).

Billing and Pharmacy Acceptance

No billing/coding specifics providedmixed

No codes listed

Pharmacy claim acceptance — system rejects charges if prescription filled at non-designated pharmacy

Association with PCPPharmacy designation is tied to the member's chosen or assigned primary care provider as part of the Restricted Recipient Program rules.

Provider, Referral, and Emergency Guidance

Prior Authorization

PCP referral required; submission within 90 days

PCP must approve all visits to other doctors or medical providers, including certain behavioral health services such as a psychiatrist, clinical nurse specialist or a methadone clinic.
Have your primary care provider write a referral BEFORE you go to the other provider and the referral must state which specialist you will see.
Primary care provider must send the referral to the Restricted Recipient Program at Hennepin Health within 90 days after the visit.

Documentation Required

Emergency and urgent care use guidance

Always use your designated hospital’s emergency room or your designated clinic’s urgent care center for emergency/urgent needs when appropriate.
For life‑threatening emergencies call 911 or go to the closest hospital.
Hospital ERs and urgent care centers should not be used for routine care that can be obtained from the PCP.

Program Definitions

Definition of the Restricted Recipient Program

Benefit protectionMembers do not lose health benefits and benefits will not be denied, reduced, or terminated because of program participation.

Program durationMembers remain in the program for either 24 or 36 months of eligibility; time accumulates and continues across plan changes or coverage gaps.

PCP requirements

Accepted PCP typesPCP must be a family practice, internal medicine, or general practice physician, a nurse practitioner, or a physician assistant.

Distance requirementPCP must be located within 40 miles of the member's home.