Section 16.03.09.913 - CRITERIA FOR LOCK-INSince it is impossible to identify all possible patterns of over utilization, and since a particular pattern may be justified based on individual conditions, no specific criteria for lock-in will be developed. However, the Department may develop guidelines for purposes of uniformity. The guidelines will not be binding on the Department and will not limit or restrict the ability of the Department to impose lock-in when any pattern of over utilization is identified. The following utilization patterns may be considered abusive, not medically necessary, potentially endangering the participant's health and safety, or over utilization of Medicaid services, and may result in the restriction of Medicaid reimbursement for a participant to a single provider or providers:
01.Unnecessary Use of Providers or Services. Unnecessary use of providers or Medicaid services, including excessive provider visits.02.Demonstrated Abusive Patterns. Recommendation from a medical professional or the participant's primary care physician that the participant has demonstrated abusive patterns and would benefit from the lock-in program.03.Use of Emergency Room Facilities. Frequent use of emergency room facilities for non-emergent conditions.04.Multiple Providers. Use of multiple providers.05.Controlled Substances. Use of multiple controlled substances.06.Prescribing Physicians or Pharmacies. Use of multiple prescribing physicians or pharmacies, or both.07.Prescription Drugs and Therapeutic Classes. Overlapping prescription drugs with the same therapeutic class.08.Drug Abuse. Diagnosis of drug abuse or drug withdrawal, or both.09.Drug Behavior. Drug-seeking behavior as identified by a medical professional.10.Other Abusive Utilization. Use of drugs or other Medicaid services determined to be abusive by the Department's medical or pharmacy consultant.Idaho Admin. Code r. 16.03.09.913