Section 29-2713. EVALUATION OF SERVICE UTILIZATION

 

2713.1Evaluation of utilization patterns may include, but are not limited to, review by the Department staff of electronic or paper records of claims submitted for prescriptions to assure compliance with the following:

 

(a) All prescription and returned prescription requirements set forth in federal, District, State laws and rules;

 

(b)Requirements governing controlled substances set forth in federal, District and State laws and rules; and

 

(c)Federal requirements pertaining to legend drugs when prescribed for their labeled use.

 

2713.2The following utilization patterns may be considered potentially abusive, not medically necessary, dangerous to the beneficiary’s health and safety, or over utilization of Medicaid services, and may result in the restriction of Medicaid reimbursement for a beneficiary to a single pharmacy:

 

(a)Recommendation from a medical professional or the beneficiary’s primary care physician that the beneficiary has demonstrated abusive patterns and would benefit from the lock-in program;

 

(b) Use of multiple pharmacies;

 

(c) Use of multiple controlled substances;

 

(d) Overlapping prescription drugs with the same therapeutic class;

 

(e) Diagnosis of drug abuse or drug withdrawal, or both;

 

(g) Drug-seeking behavior as identified by a medical professional; and

 

(h) Use of drugs or other Medicaid services determined to be abusive by the District of Columbia DUR Board. 

 

authority

The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 774; D.C. Official Code § 1-307.02 (2006 Repl. & 2011 Supp.)) and section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2008 Repl.)).

source

Notice of Final Rulemaking published at 59 DCR 2298, 2310 (March 23, 2012).