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PDFWAC 182-530-5050

Billing requirements—Point-of-sale (POS) system/prospective drug use review (Pro-DUR).

(1) Pharmacy claims for drugs and other products listed in the medicaid agency's drug file and billed to the agency by national drug code (NDC) are adjudicated by the agency's point-of-sale (POS) system. Claims must be submitted for payment using the billing unit standard identified in WAC 182-530-5000.
(2) All pharmacy drug claims processed through the POS system undergo a system-facilitated prospective drug use review (Pro-DUR) screening as a complement to the Pro-DUR screening required of pharmacists.
(3) If the POS system identifies a potential drug therapy problem during Pro-DUR screening, a message will alert the pharmacy provider indicating the type of potential problem. The alerts regarding possible drug therapy problems include, but are not limited to:
(a) Therapeutic duplication;
(b) Duration of therapy exceeds the recommended maximum period;
(c) Drug-to-drug interaction;
(d) Drug disease precaution;
(e) High dose;
(f) Ingredient duplication;
(g) Drug-to-client age conflict;
(h) Drug-to-client gender conflict; or
(i) Refill too soon.
(4) The agency provides pharmacy providers with a list of codes from which to choose in overriding POS system alert messages. These codes come from the National Council for Prescription Drug Programs (NCPDP).
(5) The dispensing pharmacist evaluates the potential drug therapy conflict and enters applicable NCPDP codes representing their professional interaction.
(a) If the resolution to the conflict satisfies agency requirements, the claim will be processed accordingly.
(b) If the resolution to the conflict does not satisfy agency requirements, the agency requires prior authorization. This includes all claims for which an alert message is triggered in the POS system and an NCPDP override code is not appropriate.
(6) The agency requires providers to retain documentation of the justification for the use of payment system override codes as described in subsections (4) and (5) of this section. The agency requires the documentation be retained for the same period as that described in WAC 182-502-0020.
(7) POS/Pro-DUR screening is not applicable to pharmacy claims included in the managed care capitated rate.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-5050, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-5050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-5050, filed 9/26/07, effective 11/1/07.]
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