DUR Rejection Codes

(Drug Utilization Review) DUR Rejection Codes

The topic of this particular page on the website is DUR Rejection Codes.  What are these codes?  DUR Codes are used to override specific insurance rejections; however, they MUST always be documented on the original paper or digital copy of the prescription and MUST be used appropriately. 

These targeted override codes are used in order to sort of "make the prescription insurance company" cover the medication, and therefore, provide the pharmacy with eventual reimbursement for supplying the patient with the drug, by billing, filling, and dispensing the medical provider prescribed product.

There are four parts, or fields, of the DUR Rejection Code.

The first field is the Conflict Code.

The second field is the Code for Professional Service.

The third field is the Code for Result of Service.

And, last but not least, the fourth and final code is the Code for Level of Effort.

Each specific, individual code taken together may be just the thing that unlocks reimbursement for a soon-to-be dispensed medical treatment.

Let's take a look at each part; each element of what makes up DUR Rejection Codes, shall we?

What are Conflict Codes? 

This element is an override for what the HMO or insurance organization has a "conflict" with.  

Let me explain.  Lets say that the insurance rejects a prescription for a reason. 

This reason could be because of one of the following:

There is an Adverse Drug Reaction = Override with Conflict Code "AR"

Or Prescription Authentication is Needed = Override with CC: "AN"

Or maybe this Drug is Interaction with Another Drug = Override with "DD"

Possibly there is a Food to Drug Interaction = Override with "DF"

The Company is Alerting us that there may be a Drug Allergy = "DA"

Perhaps the Company wants the pharmacy to call them = "CH" for Call Help Desk.

Potentially there is a kind of "stacked" or "cumulative" toxicity involving this and another drug = "AT" for Added Toxicity.

Insurance may be holding up the filling of an RX due to the fact that there is a real or potential Drug to Disease Complication = "DC" Drug Disease Inferred Precaution.

Maybe the "All Knowing" Prescription Plan prefers that a certain medication must be tried before this particular medication = "AD" Additional Drug Needed.

Patient Complaint/Symptom = "CS"

Quite possible the (again) "All Knowing" & "god-like" insurance thinks that there is misuse = "DM" Apparent Drug Misuse,

or Overuse = "ER" Precaution for Overuse,

or Dosing that is Too High = "HD" for High Dose,

or how about an excessive amount of medication = "EX" for Excessive Quantity,

or maybe specific chemical component of a product has already been prescribed (and may be already filled) and is the cause for the problem = "ID" Ingredient Duplication,

Perhaps this Drug and a Cocurrent Tobacco Use and/or Addiction is present and is causing the red flag= "DS" for Precautionary Use with Tobacco,


Back to Home

New! Comments

Have your say about what you just read! Leave me a comment in the box below.
[?]Subscribe To This Site
  • XML RSS
  • follow us in feedly
  • Add to My Yahoo!


Didn't find what you were looking for? Use the box below to search this entire site.

Custom Search



Recent Articles

  1. 1 cap po tid x10/7 days amoxicillin 500mg

    Mar 17, 19 09:58 AM

    Amoxicillin 500 mg 1cap po tid x 10/7

    Read More

  2. I got thirty pills for Vicodin 7.5 my dr wants me to take half a pill in the morning and whole pill at night how long should that last me

    Mar 15, 19 11:57 PM

    I got 30 Vicodin I have to take a half of pill in the morning and whole pill at night how long should my script last me

    Read More

  3. SILICONE RINGS IN A CLEAN ROOM

    Jan 13, 19 07:44 PM

    The USP797 rules state that no jewelry can be worn in the I.V. clean room setting because it wouldn't be sterile. I was wondering if silicone rings would

    Read More

  4. Did my pharmacist violate hips law today

    Jan 13, 19 05:34 PM

    While approaching my pharmacy counter today my pharmacist very loudly said Nicole I found out what was wrong with your suboxane P.A.Your Dr. Office done

    Read More

  5. When can it be refilled? 35 pills, 3 times a day, so it's not even.

    Jan 13, 19 04:50 PM

    35 pills, 3 times a day, so it’s not even. When do I refill?

    Read More

  6. Day Supply: Take 1 tab TID #100

    Jan 13, 19 04:26 PM

    Take 1 Tablet TID, dispense #100 Refills 2 What is the days supply for insurance?

    Read More

  7. IV vs. Oral Medication Pharmacology - Absorption or Metabolism

    Jan 13, 19 03:57 PM

    When a drug is given IV rather than orally, it eliminates the need for what? Absorption or Metabolism?

    Read More

  8. A question about Synthroid Vs. Sintrocid and drug milligrams?

    Jan 13, 19 03:37 PM

    What is the difference in 0.112mg in Synthroid and 100mcg in Sintrocid from Mexico? Would this be the same dosage?

    Read More

  9. Wondering About How Many Percocet Should be in my Bottle?

    Jan 13, 19 02:17 PM

    I had a prescription filled for my #120 Percocet on February 18th, how many of the pills should be in my bottle on March 16th? The directions are for me

    Read More

  10. How Does Nalexone Nasal Spray Help an Overdose Victim?

    Jan 01, 19 07:07 PM

    This page discusses, "How Does Nalexone Nasal Spray Help an Overdose Victim?"

    Read More

  11. Fioricet Script is for 60 pills take 2 every 8 hours How many days supply is that?

    Jan 01, 19 06:34 PM

    I have a script for Firocet. It says take 2 pills every 8 hours. It was written for 60 pills. How many days of supply is it?

    Read More

  12. Is it still a 20 day supply if “as needed” is written?

    Jan 01, 19 06:28 PM

    Percocet 5/325, qty: #60, take 1 tablet by mouth 3 times a day as needed for severe pain. Is this a 20 day supply, even though it says, “as needed?” Will

    Read More

  13. Suboxone film take 2 and 1/2 per day given quantity of 70.

    Jan 01, 19 06:16 PM

    How many days will #70 Suboxone Film last at a dose of 2 & 1/2 per day?

    Read More

  14. Diphenhydramine 25mg tablets Days Supply 2 tabs po qid #40

    Jan 01, 19 05:53 PM

    BENADRYL (diphenhydramine) 25MG TABLETS TAKE 2 TABLETS PO QID #40 NEED THE PRACTICE METHOD ON THIS BROKEN DOWN

    Read More

  15. Tresiba 200 units/ml insulin, 60 units sq qd: Days Supply and Quantity Questions

    Jan 01, 19 05:39 PM

    Tresiba 200units/ml 60 units sq qd How many individual pens will be used in 30 days and how many box(es) will be needed for a 30 day supply?

    Read More