Learning Objectives
In this module, you will learn how to identify and resolve:
- DUR Reject Error requiring pharmacist intervention
- Step Therapy rejections requiring alternative medications
- Prescriber Not Covered issues and solutions
Rejection Type 4: DUR Reject Error
DUR Reject Error - Select DUR Push Button
What it means: DUR (Drug Utilization Review) has detected a potential issue requiring pharmacist review and documentation. This ensures patient safety by flagging drug interactions, duplications, or other clinical concerns.
Common scenarios: Drug-drug interactions, therapeutic duplication, early refill, high dose alerts, or age/gender appropriateness concerns.
Example message: "DUR1: DUP THERAPY; USE OUTCOME CODES DUR2: DUP THERAPY; USE OUTCOME CODES"
Resolution Steps:
- Click the "DUR" button in the Third Party Rejects window
- This opens the DUR documentation interface
- Review all DUR alert details displayed
- Review the DUR alert details:
- What is the specific concern? (interaction, duplication, etc.)
- Which medications are involved?
- What is the severity level?
- CRITICAL: Notify pharmacist immediately
- Technicians cannot override DUR rejections independently
- RPh must review and make clinical decision
- Provide pharmacist with all relevant information
- Pharmacist will evaluate:
- Clinical significance of the alert
- Whether therapy is appropriate for the patient
- If prescriber needs to be contacted
- If patient counseling is required
- Select appropriate outcome codes (RPh decision):
- Prescriber contacted and confirmed: MD aware and wants to continue
- Patient counseled and agreed to therapy: Patient informed of risks
- Therapy discontinued: Prescriber changed medication
- Intervention not required: Alert clinically insignificant
- Other outcome codes as appropriate to the situation
- Document pharmacist intervention:
- Record what action was taken
- Document prescriber contact if made
- Note patient counseling provided
- Include clinical rationale for override
- Complete all required DUR fields:
- DUR outcome codes must be selected
- Free-text documentation may be required
- Ensure all mandatory fields are completed
- Resubmit claim with DUR information
- After pharmacist approval and documentation
- Claim should process successfully if properly documented
Rejection Type 5: Step Therapy
Step Therapy - Alternative Therapy Required First
What it means: The insurance plan requires the patient to try a different (usually less expensive) medication before they will cover the prescribed drug. Step therapy protocols ensure cost-effective treatment.
Common scenario: Brand medication requires trial of generic equivalent, or second-line therapy requires failure of first-line therapy.
Example message: "TRANS FEE = 0.03ST EDIT: TRIAL OF GENERIC DOXYCYCLINE MONOHYDRATE 100MG CAPSULES REQUIRED"
Resolution Steps:
- Review processor message for specific alternative required
- Note the exact medication that must be tried first
- Check additional messages for complete details
- Verify patient's medication history:
- Check if patient has already tried the required alternative
- Review patient profile for previous fills
- Ask patient about past medication trials
- Contact prescriber to discuss options:
- Inform them of step therapy requirement
- Share the specific alternative medication required
- Ask if prescriber wants to:
- Prescribe the required alternative first
- Submit prior authorization to override step therapy
- If patient has already tried required medication:
- Inform prescriber of previous trial
- Request prescriber submit documentation:
- Dates patient tried alternative
- Why it was ineffective or inappropriate
- Clinical justification for prescribed medication
- Prior authorization may override step therapy with proper documentation
- If prescriber writes for alternative medication:
- Process new prescription for required alternative
- Explain to patient this is the insurance requirement
- If alternative fails, prescriber can request PA for original medication
- If patient wants original medication without trying alternative:
- Explain step therapy requirement clearly
- Options available:
- Try the required alternative first (covered by insurance)
- Pay cash for prescribed medication (quote price)
- Wait for prescriber to submit PA (may take 24-72 hours)
- If PA is approved:
- Obtain PA reference number from prescriber or insurance
- Enter PA number in system
- Resubmit claim
- Document all communications:
- Note prescriber contact and outcome
- Record PA reference number if applicable
- Document patient's decision
Rejection Type 6: Prescriber Not Covered
Prescriber Not Covered
What it means: The prescriber's information submitted to insurance doesn't match their records, or the prescriber is not in the plan's network. This is often due to incorrect or outdated prescriber ID numbers.
Common scenario: Wrong NPI entered, prescriber ID not on file with insurance, or physician is not covered based on submitted prescriber ID.
Example message: "TRANS FEE = 0.03 PHYSICIAN IS NOT COVERED BASED ON SUBMITTED PRESCRIBER ID OF 1255000659"
Resolution Steps:
- Verify prescriber NPI number is correct
- Check the physical prescription for prescriber NPI
- Compare to what's entered in the system
- Look for transposed digits or data entry errors
- Check prescriber information matches prescription exactly:
- Prescriber name spelling
- NPI number
- DEA number (if controlled substance)
- All information should match the prescription
- Review additional messages for specific prescriber ID:
- Message may indicate "PRESCRIBER ID OF 1255000659" or similar
- This shows what ID the system sent
- Verify this matches the prescriber's actual ID
- Confirm prescriber is in-network:
- Some plans only cover in-network prescribers
- Check patient's insurance provider directory
- Ask patient if prescriber should be covered
- Contact insurance help desk:
- Call the processor help desk number
- Verify correct prescriber ID format for this plan
- Confirm prescriber is in their system
- Ask if prescriber needs to enroll with the plan
- Update prescriber information if needed:
- Correct any errors in the system
- Update prescriber profile with correct NPI
- Save changes to prescriber record
- If prescriber is out-of-network:
- Contact prescriber's office:
- Inform them prescription can't bill to patient's insurance
- Request they rewrite with in-network provider if available
- Or confirm they want patient to proceed
- Options for patient:
- Get new prescription from in-network provider
- Process as cash if patient willing to pay
- Check if plan allows out-of-network with higher copay
- Contact prescriber's office:
- Resubmit with corrected prescriber information
- After making any necessary corrections
- Verify claim processes successfully
- Document the issue:
- Note what correction was made
- Record help desk call if made
- Document patient communication
Key Takeaways
- DUR rejections MUST be reviewed by pharmacist - never override independently
- Step therapy requires trial of alternative medication or prior authorization
- Prescriber not covered often means incorrect NPI or out-of-network prescriber
- Document all prescriber contacts, patient communications, and resolutions
- Know when to contact help desk for guidance on complex situations