2.7 Drug Utilization Review (DUR) & Submission Clarification Codes
Key Takeaways
- Prospective Drug Utilization Review (ProDUR) screens claims electronically at point of sale for clinical safety hazards, including Drug-Drug Interactions (DD), Therapeutic Duplication (TD), and High Dose (HD).
- Resolving an NCPDP DUR alert requires populating the 3-part DUR/PPS segment: Reason for Service (Conflict Code), Professional Service Code (Intervention), and Result of Service Code (Outcome).
- Submission Clarification Codes (SCC, Field 420-DK) communicate specific dispensing circumstances to override administrative rejections.
- Crucial SCC values include SCC 03 (Vacation Supply), SCC 04 (Lost Prescription), SCC 05 (Therapy Change / Dose Increase), SCC 07 (Medically Necessary — used for urgent/emergency fills), and SCC 20 (340B Claim).
- Improper or fraudulent use of SCC overrides to bypass legitimate PBM limits without clinical documentation triggers severe audit clawbacks.
2.7 Drug Utilization Review (DUR) & Submission Clarification Codes
Prescription claims processing is not merely a financial billing pipeline; it is an active clinical safety checkpoint. Under the Omnibus Budget Reconciliation Act of 1990 (OBRA '90), pharmacies are legally required to maintain Prospective Drug Utilization Review (ProDUR) systems to screen prescription orders for clinical safety issues prior to dispensing.
When a safety issue or unique dispensing circumstance occurs, the pharmacy must communicate clinical interventions and administrative justifications to the payer. This is accomplished using the NCPDP DUR/PPS Segment (Professional Pharmacy Services) and Submission Clarification Codes (SCC).
1. Prospective DUR (ProDUR) Conflict Categories
During Gate 4 of electronic adjudication, the PBM engine screens the submitted claim against the patient's centralized 12-month prescription history across all participating network pharmacies. If a potential clinical hazard is detected, the engine triggers a ProDUR alert:
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| COMMON PRODUR SAFETY CONFLICTS |
| |
| [DD] DRUG-DRUG INTERACTION -> Co-administration causes adverse harm |
| [TD] THERAPEUTIC DUPLICATION -> Two drugs in same therapeutic class |
| [HD] HIGH DOSE / OVERDOSAGE -> Dose exceeds FDA maximum safety limit |
| [ID] INGREDIENT DUPLICATION -> Same active ingredient in 2 products |
| [PA] AGE PRECAUTION -> Inappropriate for pediatric/geriatric |
| [ER] EARLY REFILL -> Utilization threshold not met |
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| Conflict Code | Clinical Definition | Real-World Pharmacy Example |
|---|---|---|
| DD | Drug-Drug Interaction | Patient taking warfarin is prescribed ciprofloxacin (which significantly potentiates warfarin's anticoagulant effect, dramatically increasing hemorrhage risk). |
| TD | Therapeutic Duplication | Patient is prescribed lisinopril while active claims exist for losartan (concurrent use of two renin-angiotensin system blockers without clinical rationale). |
| HD | High Dose / Overdosage | Prescription written for atorvastatin 160 mg daily (FDA maximum approved dose is 80 mg daily). |
| ID | Ingredient Duplication | Prescription for Percocet (oxycodone/acetaminophen) billed while patient is actively filling Fioricet (butalbital/acetaminophen/caffeine), risking acute acetaminophen hepatotoxicity. |
| PA / SX | Age Precaution / Gender Alert | Prescription for diazepam in an 82-year-old patient (Beers Criteria warning for severe fall/fracture risk in elderly). |
| DA | Drug-Allergy Conflict | Patient with a documented anaphylactic penicillin allergy is prescribed amoxicillin. |
2. The 3-Part NCPDP DUR/PPS Segment Structure
When a ProDUR alert generates NCPDP Reject 88, the pharmacist must evaluate the clinical risk. If the pharmacist consults the prescriber or patient and determines that the medication can be safely dispensed, the claim is retransmitted with the NCPDP DUR/PPS Segment (Segment 11).
The DUR/PPS segment requires a mandatory 3-part code combination that describes the conflict, the action taken, and the clinical outcome:
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| THE 3-PART DUR/PPS CODE ARCHITECTURE |
| |
| [PART 1: REASON FOR SERVICE] -> Identifies the Conflict (e.g., DD, TD) |
| + |
| [PART 2: PROFESSIONAL SERVICE]-> Identifies the Intervention (e.g., M0, P0)|
| + |
| [PART 3: RESULT OF SERVICE] -> Identifies the Clinical Outcome (e.g., 1G)|
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1. Reason for Service Code (Conflict Code - Field 439-E4)
Identifies the clinical hazard detected (e.g., DD = Drug-Drug Interaction, TD = Therapeutic Duplication, HD = High Dose, ER = Early Refill).
2. Professional Service Code (Intervention Code - Field 440-E5)
Identifies the action taken by the pharmacy staff to investigate and resolve the hazard:
M0= Prescriber Consulted (pharmacist contacted prescriber directly).P0= Patient Consulted (pharmacist interviewed patient regarding adherence/symptoms).R0= Pharmacist Consulted Other Source (reviewed clinical compendia, lab values, or medical records).AS= Patient Assessment (performed clinical assessment or vital check).TH= Therapeutic Product Interchange (substituted formulary alternative with approval).
3. Result of Service Code (Outcome Code - Field 441-E6)
Identifies the final resolution of the clinical intervention:
1B= Filled Prescription as Written (Directions clarified/confirmed safe).1C= Filled with Different Dose (Prescriber adjusted strength/dose).1D= Filled with Different Directions (SIG clarified or altered by prescriber).1E= Filled with Different Drug (Alternative agent selected).1F= Filled with Different Quantity.1G= Filled with Prescriber Approval (Prescriber verified benefit outweighs risk).2A= Prescription Not Filled (Medication canceled due to safety hazard).2B= Prescription Not Filled - Directions Followed.
Standard DUR Override Combinations:
- Drug Interaction Approved by MD:
Reason: DD|Professional: M0|Result: 1G - Therapeutic Duplication Confirmed (Discontinuing Old Med):
Reason: TD|Professional: M0|Result: 1B - Dose Clarified & Reduced by Prescriber:
Reason: HD|Professional: M0|Result: 1C
3. Submission Clarification Codes (SCC - Field 420-DK)
While DUR codes resolve clinical safety alerts, Submission Clarification Codes (SCC) (Field 420-DK) are 2-digit numeric codes entered by the pharmacy technician or billing coordinator to clarify non-standard administrative dispensing situations.
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| HIGH-YIELD SUBMISSION CLARIFICATION CODES |
| |
| [SCC 03] VACATION SUPPLY -> Member traveling outside service area |
| [SCC 04] LOST PRESCRIPTION -> Accidental loss, spill, or theft |
| [SCC 05] THERAPY CHANGE / DOSE -> Physician increased daily dosage |
| [SCC 07] MEDICALLY NECESSARY -> Urgent / emergency dispensing fills |
| [SCC 08] COMPOUND APPROVED INGR. -> Process compound for approved ingred. |
| [SCC 20] 340B DRUG CLAIM -> Covered entity safety-net dispensing |
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| SCC Code | Title / Purpose | Operational Scenario & Workflow Requirements |
|---|---|---|
| 03 | Vacation Supply | The patient is traveling outside the plan's pharmacy network or overseas and requires an advance refill before the standard refill threshold. PBMs typically permit 1 to 2 vacation overrides per plan year. Technician documents travel dates in PMS notes. |
| 04 | Lost Prescription | The patient's medication was accidentally lost, destroyed (e.g., dropped down sink, left on airplane), or stolen. Most commercial and Medicare plans allow 1 replacement override per year per medication. Stolen controlled substances require a formal police report for audit compliance. |
| 05 | Therapy Change / Dosage Increase | The prescriber increased the patient's daily dose (e.g., from 1 tablet daily to 2 tablets daily). Because the patient consumed the previous fill at the higher rate, the supply ran out early. Submitting SCC 05 overrides Reject 79 and establishes the new dosing baseline. |
| 07 | Medically Necessary | Declares the dispensing medically necessary. Several Medicaid programs (e.g., NY Medicaid/eMedNY) direct pharmacies to use SCC 07 when dispensing an urgent or 72-hour emergency supply of a life-sustaining maintenance drug that is blocked by a Prior Authorization (Reject 75) on a weekend or holiday. |
| 08 | Process Compound for Approved Ingredients | Instructs the adjudication engine to price a multi-ingredient compound using only the covered, plan-approved ingredients. |
| 20 | 340B Drug Claim | Identifies that the dispensed drug was purchased under the federal 340B Drug Pricing Program, preventing duplicate Medicaid statutory rebates under federal law. |
A patient presents a new prescription for an increased dose of metformin (increasing from 500 mg once daily to 500 mg twice daily). The previous 30-day fill was dispensed 16 days ago and rejects with NCPDP Reject 79 (Refill Too Soon). Which Submission Clarification Code (SCC) should the billing technician apply to override the rejection?
A community pharmacy is adjudicating a claim on a Saturday evening for an urgent cardiovascular medication. The claim rejects for Prior Authorization (Reject 75), and the prescriber's office is closed until Monday. Under state Medicaid rules, which SCC should the technician submit to bill an immediate 72-hour emergency supply?
A pharmacist evaluates an electronic DUR alert for a severe Drug-Drug Interaction (DD) between a newly prescribed antibiotic and a chronic cardiac drug. The pharmacist contacts the prescribing physician, who confirms that the patient will be closely monitored and instructs the pharmacy to dispense the antibiotic as written. Which 3-part NCPDP DUR/PPS segment code combination must be submitted?
Which of the following clinical conflicts detected during Prospective Drug Utilization Review (ProDUR) describes a scenario where an adjudication engine flags concurrent active claims for two different ACE inhibitors (e.g., lisinopril and enalapril)?