On June 22, the Department of Health Care Services (DHCS) and its Medi-Cal Rx contractor Magellan announced that effective July 22 , pharmacy claim edits for diagnosis and drug utilization review (DUR) requirements will be reinstated.
Specifically, claims will reject for National Council for Prescription Drug Programs (NCPDP) “Reject Code 80 – Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria” and DUR NCPDP “Reject Code 88 – Drug Utilization Review Reject Error” for DUR alerts such as drug-drug interactions, high dose, and early refill.
DHCS and Magellan also posted reference guides for Reject Code 80 and Reject Code 88, along with an appendix, that provide additional information on these reject codes and processes to remediate claims that have been denied as a result of these reinstated claim edits.
DHCS and Magellan also announced new point-of-sale messaging to align with the extension of the 180-day transition policy. Previous messaging stated that the 180-day transition policy was expiring on July 1, 2022, and after that date, the prescription would require an approved prior authorization. However, new messaging will state that the transition policy has been extended and no prior authorization is required.