Billing L&I for Pharmacy Services

Screenings

All pharmacy bills will be screened for:

  • Drug utilization review (DUR) criteria, such as high dose, therapeutic duplication and level 1 drug-to-drug interactions,
  • Preferred drug list (PDL) provisions,
  • 30-day supply limit, and
  • Formulary status including the PDL.

Rejections associated with these screenings must be addressed by the dispensing pharmacist before the bills will be payable.

How to override DUR edits

When a DUR condition exists on a bill, the POS system will send rejection code 88. After conducting a review, the dispensing pharmacist may use the appropriate NCPDP DUR conflict, intervention and outcome codes to override the denial if it is medically appropriate. See the NCPDP Payer sheet (97 KB PDF).

How to override PDL provisions

The dispensing pharmacist must interchange a preferred drug for a non-preferred drug when prescribed by an endorsing practitioner unless "dispense as written" or DAW is noted on the prescription.

Non-preferred drug prescribed by endorsing practitioner

When you bill for a non-preferred drug written by an endorsing practitioner and substitution is permitted, the POS system will send:

  • Rejection code 70,
  • A secondary message, "TIP Preferred:"
  • Notice that a therapeutic interchange is required.

If the endorsing practitioner indicates DAW on the initial prescription, you must bill L&I using a value of 1 in the DAW field.

Non-preferred drug prescribed by non-endorsing practitioner

When you bill for a non-preferred drug written by a non-endorsing practitioner, the POS system will send:

  • Rejection code 70,
  • A secondary message, "Alternatives:"
  • Notice that a new prescription for a preferred drug is required.

If you receive an initial prescription after normal business hours or during weekends or Washington State holidays, you may:

  • Dispense the non-preferred drug and
  • Bill L&I using a value of 6 in the DAW field.

Your request must be made to L&I before further coverage is provided.

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