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Screenings
All pharmacy bills will be screened for:
- Drug utilization review (DUR) criteria, such as high dose, therapeutic duplication and level 1 drug-to-drug interactions,
- Preferred drug list (PDL) provisions,
- 30-day supply limit, and
- Formulary status including the PDL.
Rejections associated with these screenings must be addressed by the pharmacist before bill will be payable.
How to override DUR edits
When a DUR condition exists on a bill, the POS system will send reject code 88. After the pharmacist have conducted a review, you must use the appropriate NCPDP DUR conflict, intervention and outcome codes to override the denial if it is medically appropriate. See the NCPDP Payer sheet (97 KB PDF).
How to override PDL provisions
Pharmacist must interchange a preferred drug for a non-preferred drug when prescribed by an endorsing practitioner unless "dispense as written" or DAW is noted on the prescription.
For non-preferred drug by endorsing practitioner
When you bill for a non-preferred drug written by an endorsing practitioner and substitution is permitted, the POS system will:
- Send reject code 70,
- A secondary message, "TIP Preferred:"
- Notify you that a therapeutic interchange is needed.
If the endorsing practitioner indicates DAW on the initial prescription, you must bill L&I using a value of 1 in the DAW field.
For non-preferred drug by non-endorsing practitioner
When you bill for a non-preferred drug written by a non-endorsing practitioner, the POS system will:
- Send reject code 70,
- A secondary message, "Alternatives:"
- Notify you that a new prescription for a preferred drug is needed.
If you receive an initial prescription after normal business hours or during weekends or Washington State holidays, you may:
- Dispense the non-preferred drug and
- Bill L&I using a value of 6 in the DAW field.
Your request must be made to L&I before further coverage is provided.
