Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-530 - Prescription drugs (outpatient)
BILLING
Section 182-530-5050 - Billing requirements - Point-of-sale (POS) system/prospective drug use review (Pro-DUR)

(1) Pharmacy claims for drugs and other products listed in the medicaid agency's drug file and billed to the agency by national drug code (NDC) are adjudicated by the agency's point-of-sale (POS) system. Claims must be submitted for payment using the billing unit standard identified in WAC 182-530-5000.

(2) All pharmacy drug claims processed through the POS system undergo a system-facilitated prospective drug use review (Pro-DUR) screening as a complement to the Pro-DUR screening required of pharmacists.

(3) If the POS system identifies a potential drug therapy problem during Pro-DUR screening, a message will alert the pharmacy provider indicating the type of potential problem. The alerts regarding possible drug therapy problems include, but are not limited to:

(4) The agency provides pharmacy providers with a list of codes from which to choose in overriding POS system alert messages. These codes come from the National Council for Prescription Drug Programs (NCPDP).

(5) The dispensing pharmacist evaluates the potential drug therapy conflict and enters applicable NCPDP codes representing their professional interaction.

(6) The agency requires providers to retain documentation of the justification for the use of payment system override codes as described in subsections (4) and (5) of this section. The agency requires the documentation be retained for the same period as that described in WAC 182-502-0020.

(7) POS/Pro-DUR screening is not applicable to pharmacy claims included in the managed care capitated rate.