DUR Rejections

The HHSC system provides information regarding therapeutic duplication, ingredient duplication, maximum dosage, and significance level 1 and 2 (First Data Bank) drug-drug interactions for those prescriptions paid by Medicaid, CSHCN, or KHC programs. Since some people are limited to a specific number of prescription drug claims per month, the person’s medication record at the dispensing pharmacy must be reviewed to ensure the inclusion of a complete drug history in the prospective DUR process. Drug allergy and disease state information will not be available online, and will also have to be reviewed from the person’s medication record.

The selected claims with the greatest potential for adverse therapeutic outcomes will reject with NCPDP error code “88” ("DUR Reject Error").

Pharmacy providers will have the ability to override the DUR rejection by submitting the “DUR Reason for Service Code”, “DUR Professional Service Code”, and “DUR Result of Service Code” fields on the claim if it is determined the prescribing provider understands the risk to be acceptable, and appropriate monitoring measures are undertaken. The override can also be submitted on the initial claim submittal, if appropriate, thus bypassing the rejection. The override capability will allow payment of the rejected claims when appropriate without pharmacy intervention.

Refer to the Claims Billing (B1) Transaction for specific transaction, segment, and field requirements.

Field Name Field Number Accepted Values
DUR Reason for Service 439-E4

DD - Drug-Drug Interaction
HD - High Dose
ID - Ingredient Duplication
TD - Therapeutic Duplication

DUR Professional Services Code 44Ø-E5

ØØ - No Intervention
MØ - Prescriber Consulted
PØ - Patient Consulted
RØ - Pharmacist consulted other source

DUR Result of Service Code 441-E6

1A - Filled As Is, False Positive
1B - Filled Prescription As-Is
1C - Filled, With Different Dose
1D - Filled, With Different Directions
1F - Filled, With Different Quantity
1G - Filled, With Prescriber Approval
4A  - Prescribed with acknowledgement

Only claims paid through the HHSC system are screened for interactions, duplication, and maximum dosage online. It is necessary the required Patient Medication Record (PMR) be reviewed for additional drugs not paid by Medicaid, CHIP, CSHSN, or KHC. This is especially important for those people limited to three prescriptions per month. The PMR must also be reviewed by pharmacist to evaluate drug disease contraindications, drug allergy interactions, and duration of drug treatment since this information is not in the VDP system at this time.