Indiana § 12-15-35-39 Retrospective DUR requisites

Indiana Statutes

§ 12-15-35-39 — Retrospective DUR requisites

Indiana·Art. 15 MEDICAID·Ch. 35 Drug Utilization Review

Retrospective DUR must:

(1)be based on the guidelines established by the board; and

(2)use the mechanized drug claims processing and information retrieval system to analyze claims data to do the following:

(A)Identify patterns of fraud, abuse, gross overuse, and inappropriate or medically unnecessary care.

(B)Assess data on drug use against explicit predetermined standards that are based on the compendia and other sources to monitor the following:

(i)Therapeutic appropriateness.

(ii)Overutilization or underutilization.

(iii)Therapeutic duplication.

(iv)Drug-disease contraindications.

(v)Drug-drug interactions.

(vi)Incorrect drug dosage or duration of drug treatment.

(vii)Clinical abuse and misuse.

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Retrospective DUR must:
(1) be based on the guidelines established by the board; and
(2) use the mechanized drug claims processing and information
retrieval system to analyze claims data to do the following:
(A) Identify patterns of fraud, abuse, gross overuse, and
inappropriate or medically unnecessary care.
(B) Assess data on drug use against explicit predetermined
standards that are based on the compendia and other sources to
monitor the following:
(i) Therapeutic appropriateness.
(ii) Overutilization or underutilization.
(iii) Therapeutic duplication.
(iv) Drug-disease contraindications.
(v) Drug-drug interactions.
(vi) Incorrect drug dosage or duration of drug treatment.
(vii) Clinical abuse and misuse.

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