The Prospective Drug Utilization Review process follows the National Council for Prescription Drug Pricing (NCPDP) ProDUR standard formats for conflict, intervention, and outcome. These formats are found in the SDMCD Technical Specifications, Table 9 and 10 (see pages 11 and 12) . The department has the capability to control which of the conflicts in Table 9 will result in a denial of a claim. The "Early Refill" or ‘ER’ code will be the first conflict in place, with other conflicts added to production over a period of several months. In order for the early refill alert to function properly, the correct days supply must be entered on the claim.
Also, note that the override process is not the same as with some of the private insurers/processors. They use the 420-DK field and position, while SDMCD will use only those codes found in the ProDUR tables.
An example of how to override a denial for an early refill is to enter 3 codes. To override a denied claim because of a ProDUR edit required the entry of three codes in the appropriate locations:
In Summary: Should SDMCD choose to deny (reject) claims because of a prospective drug utilization review alert, the POS/ProDUR system will allow the pharmacist to override the rejection using entry of 3 codes: the Conflict code, the Intervention code and the Outcome code. These codes are located in Tables 9 and 10. One code from each column is required to override a denied claim which results from ProDUR alert. Please review the process with your software vendor to ensure a smooth implementation.
Overrides of the early refill denial must be medically necessary and consistent with the recipient’s symptoms, diagnosis, condition, or injury. Use of the override process in not for the convenience of the recipient or the provider. Accurate day supply information is required for the early refill alert.
Pharmacist may retract any claim that has been paid or captured by submitting an NCPDP reversal transaction. Reversals may be used in many circumstances. Examples:
If a claim has been denied for any reason, you may rebill via the POS system if you think the claim should be payable, making any needed claim corrections. Example: If the claim is denied because the medical assistance ID number is invalid, correct the ID number and resubmit.