DUR reject error
Also known as: drug utilization review rejection, DUR rejection
A DUR reject error is an insurance claim rejection triggered by a drug utilization review — the payer's automated safety screen flags a potential problem, such as a drug interaction or early refill, that must be reviewed before the claim can process.
A DUR reject error occurs when a pharmacy submits a prescription claim and the insurance payer's drug utilization review (DUR) system rejects it. DUR is an automated safety and appropriateness screen that checks each claim against the patient's medication history and plan rules before the insurer agrees to pay.
Common triggers include potential drug-drug interactions with another medication on the patient's profile, therapeutic duplication (two drugs from the same class), a dose above or below the usual range, early refills suggesting overuse, drug-age or drug-pregnancy precautions, and drug-disease conflicts. The rejection message includes codes describing the conflict detected.
A DUR reject is not necessarily a final denial — it is a stop sign requiring human review. The pharmacist evaluates the flagged issue, may consult the prescriber, and can often resubmit the claim with DUR override codes documenting the reason for service, the professional service performed, and the result. Some rejects, such as a genuine dangerous interaction, lead instead to a therapy change. Pharmacy technicians play a key role in recognizing DUR rejects and routing them to the pharmacist, since only the pharmacist can make the clinical judgment.
The PTCE tests third-party claim processing, including DUR rejections, within its order entry and processing domain. Know what DUR stands for, the common reject reasons, and that flagged claims require pharmacist review before an override or resubmission.
Key takeaways
- DUR stands for drug utilization review — an automated payer screen on every prescription claim.
- A DUR reject flags a potential safety or appropriateness issue, such as an interaction, duplication, high dose, or early refill.
- A DUR reject requires pharmacist review; many claims can be resubmitted with override codes after evaluation.
- Technicians identify and route DUR rejects, but the clinical judgment belongs to the pharmacist.
- The PTCE tests DUR rejections as part of insurance claim processing.