Section 182-530-4050 - Drug use and claims review(1) The agency's drug use review (DUR) consists of: (a) A prospective drug use review (Pro-DUR) that requires all pharmacy providers to: (i) Obtain patient histories of allergies, idiosyncrasies, or chronic condition or conditions which may relate to drug utilization;(ii) Screen for potential drug therapy problems;(iii) Counsel the patient in accordance with existing state pharmacy laws and federal regulations; and(iv) Obtain authorization as described in WAC 182-530-3200 prior to dispensing when required by the agency or an agency designee.(b) A retrospective drug use review (Retro-DUR), in which the agency provides for the ongoing periodic examination of claims data and other records in order to identify patterns of fraud, abuse, gross overuse, excessive utilization, inappropriate or medically unnecessary care, or prescribing billing practices that indicate abuse or excessive utilization among physicians, pharmacists, and individuals receiving benefits.(2) The agency reviews a periodic sampling of claims to determine if drugs are appropriately ordered, prescribed, administered, dispensed, and billed. If a review of the sample finds that a provider is inappropriately ordering, prescribing, administering, dispensing, or billing for drugs, the agency may implement corrective action that includes, but is not limited to:(a) Educating the provider regarding the problem practice or practices;(b) Requiring the provider to maintain specific documentation in addition to the normal documentation requirements regarding the provider's ordering, prescribing, administering, dispensing, or billing practices;(c) Applying additional provider-specific requirements for obtaining authorization prior to ordering, prescribing, administering, dispensing, or billing for drugs;(d) Recouping the payment for the drug or drugs; or(e) Terminating the provider's core provider agreement (CPA).Wash. Admin. Code § 182-530-4050
Amended by WSR 16-01-046, Filed 12/9/2015, effective 1/9/2016Amended by WSR 20-06-077, Filed 3/4/2020, effective 4/4/202011-14-075, recodified as § 182-530-4050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 07-20-049, § 388-530-4050, filed 9/26/07, effective 11/1/07.