DUR Codes

The Prospective Drug Utilization Review (ProDUR) process promotes optimal and cost-effective use of pharmaceuticals, lessens the chance of unnecessary or inappropriate use of medications, helps identify possible drug-related problems, and promotes optimal clinical outcomes. 

Prospective DUR occurs during point-of-sale claims adjudication, before the prescription is dispensed.  The DUR modules analyze paid claims history to determine whether the current prescription is in conflict with any other prescriptions for the recipient. 

If any of the potential problems described below are detected, the PDCS immediately sends a DUR response to the pharmacist.  These responses are specifically formatted to provide precise information regarding the conflict.  These messages will accompany a claim regardless of its payment status.

  • Therapeutic Duplication Alert (Reject 88, EOB 707, Conflict TD)
  • Drug-Drug Interaction Alert (Reject 88, EOB 702, conflict code DD)
  • High Dose (Reject 88, EOB 700, Conflict HD)
  • Low Dose Alert (88, EOB 720, Conflict LD)
  • Ingredient Duplication Alert ((Reject 88, EOB 719, Conflict ID)
  • Age Precaution Alert (Reject 88, EOB 705, Conflict PA)
  • Gender Precaution Alert (Reject 88, EOB 733, Conflict SX)
  • Maximum Duration of Therapy Alert (Reject 88, EOB 734, Conflict MX)
  • Pregnancy Alert (Reject 88, EOB 706, Conflict PG)

A summary of the NCPDP Conflict, Intervention, and Outcome Codes which pharmacies may use to override the alerts discussed above, are provided below.  An intervention/outcome code is only needed for denied claims.  Some ProDUR edits and set to “post and pay”.

Edit 88 – Drug Utilization Review Conflict Code Table

DUR Conflict Code

Description

PA

Age Alert

SX

Gender Alert

LD

Low Dose

HD

High Dose

ER

Early Refill

TD

Therapeutic Duplication

ID

Ingredient Duplication

DD

Drug-Drug Interaction

MX

Excessive Duration

 

DUR Intervention Code Table

Code

Meaning

Code

Meaning

MD Interface

TH

Therapeutic Product Interchange

Patient Interaction

AS

Patient Assessment

Pharmacist Reviewed

DE

Dosing Evaluation/Determination

CC

Coordination of Care

GP

Generic Product Selection

FE

Formulary Enforcement

MR

Medication Review

MA

Medication Administration

PH

Patient Medication History

PE

Patient Evaluation/Instruction

PT

Perform Laboratory Tests

PM

Patient Monitoring

SC

Self-Care Consultation

RT

Recommended Laboratory Test

TC

Payer/Processor Consulted

SW

Literature Search/Review

   

 

DUR Intervention Code Table

Code

Meaning

Code

Meaning

1A

Filled – False Positive

1F

Filled – Different Quantity

1B

Filled as is

1G

Filled after prescriber approval

1C

Filled with different dose

2A

Not Filled

1D

Filled with different directions

2B

Not Filled – Directions Clarified
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