Comparing prescription to allowed condition

While it is not possible to determine if an outpatient medication is medically necessary at the point of service, an outpatient drug bill adjudication edit compares the approved and widely-accepted uses of the medication being dispensed based on the submitted National Drug Code (NDC) and the International Classification of Diseases (ICD-9) code(s) allowed in the claim. This NDC/ICD-9 edit process helps ensure that a prescribed medication is reasonably related to the treatment of an allowed condition. This edit process only impacts claims with a date of injury on and after Feb. 1, 2000.

If injured workers and their prescribing physicians disagree with the decision, the physician can appeal the reimbursement determination to the Pharmacy Benefits Manageer (PBM). The pharmacist cannot appeal the decision. Injured workers and their representatives will receive correspondence with information about appealing the reimbursement decision.

Click here for PBM contact information.