Medicaid program; drug use review program and electronic claims management system for outpatient drug claims--HCFA. Final rule.
This final rule revises some of the regulatory requirements for the drug use review (DUR) program for covered outpatient drugs furnished to recipients under the Medicaid program. The regulatory requirements became effective on January 2, 1993, as a result of an interim final rule with comment period that we published on November 2, 1992. Specifically, these revisions-- Clarify the definitions of overutilization, underutilization, consensus process, peer-reviewed literature, adverse medical result, adverse drug-drug interaction, appropriate and medically necessary, and individual medical history; Change the requirements for licensure of DUR board members, and telephone counseling arrangements for mail order pharmacies; Include non-prescription drugs in the consideration of alteration of therapeutic effect; Require hospitals to give assurances that they have met the requirements of the statute before claiming the hospital exemption from DUR; Specify the issues that State agencies must address when formulating counseling standards; Clarify the bases for DUR board recommendations; Clarify the distinction between DUR and surveillance and utilization review (SUR); and Make certain technical and editorial corrections. The November 1992 interim final rule with comment period incorporated and interpreted certain provisions of section 4401 of the Omnibus Budget Reconciliation Act of 1990.
D014487:Centers for Medicare and Medicaid Services, U.S.; D017723:Drug Utilization Review / Q000331:legislation & jurisprudence*; D007345:Insurance Claim Review / Q000331:legislation & jurisprudence*; D007356:Insurance, Pharmaceutical Services / Q000331:legislation & jurisprudence*; D008484:Medicaid / Q000331:legislation & jurisprudence*; D014481:United States