Pharmacy Point-of-Sale:
Prospective DUR Denials and Override Procedures

 

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.

EARLY REFILL OVERRIDE

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:

1.	the Conflict Code (from table 9 as returned by SDMCD on a denied claim)
2.	the Intervention Code* (from table 10)
3.	the Outcome Code (from table 10)
*The Intervention codes (table 10) are alpha-numeric. Examples M0 (zero), P0 (zero), and R0 (zero). However, the intervention code 00 is zero, zero (numeric, numeric)

POS OVERRIDE

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.

CONFLICT CODES		INTERVENTION CODES		OUTCOME CODES
(SEE TABLE 9)		(SEE TABLE 10)		(SEE TABLE 10)
ER	Early Refill	M0 *	Prescriber Consulted	1A	---------------------
DD	Drug Drug Interaction	P0 *	Patient Consulted	1B	Filled Rx as is
ID	Duplicate Therapy Same	R0 *	Pharmacist Consulted Other Source	1C	Filled With Different Dose
TD	Therapeutic Duplication	00 *	----------	1D	Filled With Different Dose
MC	Medical Disease (diagnosed) Contraindicated	Blank	-----------	IE	------------------------
DC	Drug Disease Contraindicated	--------------------------		IF	Filled With Different Quantity
HD	Adult, Geriatric, or Pediatric High Dose	--------------------------		IG	Filled With Prescriber Approval
LD	Adult, Geriatric or Pediatric Low Dose	--------------------------		2A	--------------------
AT	Additive Toxicity	--------------------------		2B	---------------------
IC	Iatrogenic Side Effect (Inferred)	--------------------------		--------------------------

* Theses are not the alpha letter "o", they are the number zero "0".

EARLY REFILL OVERRIDES AND DAYS SUPPLY

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.

POINT-OF-SALE (POS) REVERSALS

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:

a.	A prescription is not picked up by the patient;
b.	The quantity dispensed is changed or not utilized;
c.	Prospective Drug Utilization Review (ProDUR) information provided by the system as a claim was paid results in a prescription not being dispensed or being modified. If modified, the new claim may be submitted at any time after the reversal; and
d.	An error was made when submitting the claim. A corrected claim may be submitted and processed at any time after the reversal. Generally, a reversal and resubmission can be used in place of the hard copy adjustment form.

DENIED POS CLAIM

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.

Pharmacy Point-of-Sale