Gateway Protects You and Your Loved Ones
Gateway Health’s Recipient Restriction Program is a program to detect and deter member misutilization, fraud and/or abuse.
This program restricts members to one primary care physician (PCP) and/or one participating pharmacy of the member’s choice for a period of five years.
Gateway contacts the member’s physician and pharmacy of choice to ask if they would be willing to accept a restricted member.
Our program interfaces with the Department of Human Services (DHS) centralized Recipient Restriction Program.
This enables DHS to continue the restrictions for a five-year period across the Pennsylvania Medical Assistance Program.
Once a member is identified for this program through referrals from participating pharmacies or physicians or generated utilization reports,
a complete review of pharmacy and medical claims data is performed. Upon completion of review, if misutilization, fraud and/or abuse can be documented
and has met the DHS approved restriction criteria, the member is recommended for restriction to a PCP and/or participating pharmacy. Upon approval from
Gateway’s Recipient Restriction Committee and DHS, the member is then restricted or “locked-in” to one PCP and/or one participating pharmacy.
Please note: The restriction is not enforced in the case of an emergency. Please contact Gateway Health for assistance if this situation occurs.