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PDFWAC 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; and
(iii) Counsel the patient in accordance with existing state pharmacy laws and federal regulations.
(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, or inappropriate or medically unnecessary care among physicians, pharmacists, and individuals receiving benefits.
(2) The agency reviews a periodic sampling of claims to determine if drugs are appropriately dispensed and billed. If a review of the sample finds that a provider is inappropriately 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 dispensing or billing actions;
(c) Recouping the payment for the drug or drugs; or
(d) Terminating the provider's core provider agreement (CPA).
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-4050, filed 12/9/15, effective 1/9/16. WSR 11-14-075, 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. WSR 07-20-049, § 388-530-4050, filed 9/26/07, effective 11/1/07.]
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