Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 27 - Department of Medical Services › Rule 016.27.20-005 - SPA # 2019-002, Section 1004 of the SUPPORT Act

Current through Register Vol. 49, No. 6, June, 2024
Revision: HCFA-PM- (MB)
State/Territory:
ARKANSAS
Citation
1927(g)(2)(C) 42 CFR 456.709(b)
F.2. The DUR program assesses data on drug use against
						  explicit predetermined standards including but not limited to monitoring
						  for:
-Therapeutic appropriateness
-Overutilization and underutilization
-Appropriate use of generic products
-Therapeutic duplication
-Drug-disease contraindications
-Drug-drug interactions
-Incorrect drug dosage/duration of drug
						  treatment
-Clinical abuse/misuse
1927(g)(2)(D) 42 CFR 456.711
3. The DUR program through its State DUR Board, using
						  data provided by the Board, provides active and ongoing educational outreach
						  programs to educate practitioners on common drug therapy problems to improve
						  prescribing and dispensing practices.
1927(g)(3)(A) 42 CFR 456.716(a)
G.1. The DUR program has established a State DUR Board
						  either:
X
Directly, or
__Under contract with a private organization
1927(g)(3)(B) 42 FR 456.716 (A) and (B)
2. The DUR Board membership includes health
						  professionals (
at least 1/3 but no more than fifty-one percent (51%)
						  licensed and actively practicing physicians and at least 1/3 licensed and
						  actively practicing pharmacists
) with knowledge and experience in one
						  or more of the following:
-Clinically appropriate prescribing of covered
						  outpatient drugs.
-Clinically appropriate dispensing and monitoring of
						  covered outpatient drugs.
-Drug use review, evaluation and intervention.
-Medical quality assurance.
1927(g)(3)(C) 42 CFR 456.716(d)
3. The activities of the DUR Board include:
-Retrospective DUR,
-Application of Standards as defined in section
						  1927(g)(2)(C), and
-Ongoing interventions for physicians and pharmacists
						  targeted toward therapy problems or individuals identified in the course of
						  retrospective DUR.
1927(g)(3)(C) 42 CFR 456.711(a)-(d)
G.4. The interventions include in appropriate
						  instances: -Information dissemination -Written, oral, and electronic reminders
						  -Face-to-Face discussions -Intensified monitoring/review of
						  prescribers/dispensers
P.L.
						  115-271 Section 1004 of the SUPPORT
						  Act
H.1. The DUR program meets the requirements of
						  Section 1004 of the SUPPORT Act for substance use-disorder prevention that
						  promotes opioid recovery and treatment. Opioid claim review limitations for
						  initial and subsequent refills require prospective safety edits and
						  comprehensive retrospective claims review processes.
a) Prospective point-of-sale safety edits
*
Therapeutic duplication edit
*
Maximum daily quantity edit
*
Maximum monthly quantity edit
*
Morphine Milligram Equivalent edit
*
Refill too soon logic
*
Age edit
*
Maximum days' supply edits for treatment
naïve and treatment experienced
b) Retrospective claims review
*
Morphine Milligram Equivalent review per
						  recipient and prescriber
*
Concurrent opioid and benzodiazepine usage
						  prompts prescriber or pharmacy provider notification by letter
*
Concurrent opioid and antipsychotic medication
						  usage prompts prescriber or pharmacy provider notification by letter
*
Review opioid use in adolescents
*
Review prescribing and dispensing patterns on
						  opioid claims
*
Retrospective reviews on opioid prescriptions
						  exceeding these above limitations on an ongoing basis
Citation
H.2. Program to monitor antipsychotic medication
						  use by children
a) Prospective point-of-sale edits
*
Age edits for recipients < 18 years
						  old
*
Therapeutic duplication edit
*
Maximum dose edit
*
Antipsychotic medication usage in children
						  including those in foster care are monitored in monthly reports by a staff
						  psychiatrist
*
Routine metabolic labs required
b) Retrospective claims review
*
Monitor antipsychotic use patterns in children
						  including foster care
*
Doses of antipsychotic medications monitored
						  H.3. Fraud and Abuse Identification
a) Lock-in program for recipients identified by
						  Retrospective DUR for possible abuse or misuse of controlled substances
b) Prescriber and pharmacy provider patterns of
						  misuse/overprescribing
*
Identified by Retrospective DUR
*
Identified by contracted auditor(s)
c) Prescription Drug Monitoring programs enable
						  prescribers and pharmacy providers to search the PDMP for monitoring narcotic
						  use behavior including access to other states
1927(g)(3)(D)
						  42
						  CFR 456.712(A) and (B)
I. The State assures that it will prepare and
						  submit an
X
annual report to the Secretary, which
						  incorporates a report from the State DUR Board, and that the State will adhere
						  to the plans, steps, procedures as described in the report.
1927(h)(1)
						  42 CFR
						  456.7221927(g)(2)(A)(i)
J.1. The State establishes, as its principal
						  means of processing claims for covered outpatient drugs under this title, a
						  point-of-sale electronic claims management system to perform on-line:
-real time eligibility verification
-claims data capture
-adjudication of claims
-assistance to pharmacists, etc. applying for
						  and
receiving payment.
42 FR 456.705(b)
_ 2. Prospective DUR is performed using an
						  electronic point of sale drug claims processing system.
1927(j)(2)
						  42 CFR
						  456.703(c)
K. Hospitals which dispense covered outpatient
						  drugs are exempted from the drug utilization review requirements of this
						  section when facilities use drug formulary systems and bill the Medicaid
						  program no more than the hospital's purchasing cost for such covered outpatient
						  drugs.