CONFIDENTIAL AND PROPRIETARY
Clinical Overrides on Claim Rejections
Walgreens Health Initiatives maintains a profile of each patient’s medication history, consisting of all pharmacy claims submitted by any pharmacy provider. The system screens for potential problems against pharmacy and medical information and returns an edit (alert) where appropriate via the on-line Point-of-Service (POS) claims adjudication system.
Once a claim has been rejected due to a drug safety conflict, an “88 – DUR reject” error will be issued in the claim response status segment, and specific DUR reject information will be found in the response DUR/PPS segment. Viewing and access to the specific DUR information is dependant and specific to the pharmacy’s claims processing software. This error at the plan sponsor’s discretion may be overridden at the point of sale using NCPDP conflict, intervention and outcome codes (Table 1), and does not typically require prior authorization from the plan sponsor. The decision on how to best process the interaction is subject to the professional judgment of the network pharmacist.
Refill too soon edits (Conflict Code = ER) are typically not allowed to be overridden by the network pharmacy and may require a plan sponsor authorization.
Conflict Codes Field 439-E4
DC MC DA DD HD TD DC LD MN MX PA
Drug Disease Inferred Drug Disease Known Drug Allergy Drug-Drug Interaction High Dose Therapeutic Duplication Drug-Disease (Inferred) Low Dose Insufficient Duration Excessive Duration Drug-Age
Intervention Codes Professional Service Code Field 440-E5
AS CC DE FE GP MA MØ MR PE PH PM PØ PT RØ RT SC SW TC TH
Patient Assessment Coordination of Care Dosing Evaluation Formulary Enforcement Generic Product Selection Medication Administration Prescriber consulted Medication Review Patient Education Patient Medication History Patient Monitoring Patient consulted Perform Lab Test Pharmacist consulted other source Recommend Lab Test Self-Care Consultation Literature Search/Review Payer/Processor consulted Therapeutic Product Interchange
Table 1: NCPDP conflict, intervention and outcome codes
Walgreens Health Initiatives – Pharmacy Manual