Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-270 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this part shall
					 have the following meanings unless the context clearly indicates
					 otherwise:
"Abuse" means
(i)
				  use of health services by recipients which is inconsistent with sound fiscal or
				  medical practices and that results in unnecessary costs to the Virginia
				  Medicaid program or in reimbursement for a level of use or a pattern of
				  services that is not medically necessary, or (ii) provider practices which are
				  inconsistent with sound fiscal or medical practices and that result in (a)
				  unnecessary costs to the Virginia Medicaid program, or (b) reimbursement for a
				  level of use or a pattern of services that is not medically necessary or that
				  fails to meet professionally recognized standards for health care.
"Appropriate and medically necessary" means drug
					 prescribing and dispensing practices which conform with the criteria and
					 standards developed pursuant to this regulation and are consistent with the
					 diagnosis or treatment of an identified condition.
"Criteria and standards" means predetermined objective
					 tests established by or approved by the Drug Utilization Review Board for use
					 in both retrospective and prospective screening of the quality and
					 appropriateness of pharmacy services for Medicaid recipients. Objective tests
					 shall include both criteria, which are based upon professional expertise, prior
					 experience, and the professional literature with which the quality, medical
					 necessity, and appropriateness of health care services may be compared, and
					 standards, which are professionally developed expressions of the range of
					 acceptable variation from a criterion.
"Code" means the Code of Virginia.
"DMAS" means the Department of Medical Assistance Services
					 consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code
					 of Virginia.
"Director" means the Director of DMAS.
"Drug Utilization Review (DUR)" means a formal continuing
					 program for assessing medical and recipients' drug utilization data against
					 explicit standards and criteria and, as necessary, introducing remedial
					 strategies.
"Drug Utilization Review Board (DUR Board)" means the group
					 of health care professionals appointed by the director and established pursuant
					 to § 1927(g)(3) Title XIX of the Social Security Act.
"Drug Utilization Review Committee (DUR Committee)" means a
					 committee composed of health care professionals who make recommendations for
					 developing and modifying drug therapy review standards or criteria, participate
					 in retrospective reviews, recommend remedial strategies, and evaluate the
					 success of the interventions.
"Exceptional drug utilization pattern" means a pattern of
					 drug use that differs from the standards and criteria established pursuant to
					 this part.
"Fraud" means any act including intentional deception or
					 misrepresentation that constitutes fraud under applicable federal or state
					 laws.
"OBRA 90" means the Omnibus Budget Reconciliation Act of
					 1990.
"Patient's agent" means the person or persons selected by
					 the recipient to act on his behalf with regard to the recipient's receipt of
					 Title XIX pharmacy services.
"Patient counseling" means communication of information by
					 the pharmacist, in person whenever practicable, to patients receiving benefits
					 under Title XIX of the Social Security Act or the patient's agent, to improve
					 therapeutic outcomes by encouraging proper use of prescription medications and
					 devices.
"Prospective drug utilization review" means a review by the
					 pharmacist of the prescription medication order and the patient's drug therapy
					 before each prescription is filled. The review shall include an examination of
					 any patient profile (which has been maintained by the pharmacist) to determine
					 the possibility of potential drug therapy problems due to therapeutic
					 duplication, drug-disease contraindications, drug-drug interactions (including
					 serious interactions with nonprescription or over-the-counter drugs, incorrect
					 drug dosage or duration of drug treatment, drug-allergy interactions, and
					 clinical abuse or misuse).
"Restriction" means
(i) an administrative limitation imposed by
				  DMAS on a recipient which requires the recipient to obtain access to specific
				  types of health care services only through a designated primary provider or
(ii) an administrative limitation
				  imposed on a provider to prohibit participation as a designated primary
				  provider, referral provider, or covering provider for restricted recipients.
"Retrospective drug utilization review" means the drug use
					 review process that is conducted by DMAS using historic or archived medical or
					 drug use data which may include but is not restricted to patient profiles and
					 historical trends.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.