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,

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