HAR §17-1739.1-13. Drug use review (DUR) board

(a) An advisory drug use review board shall be appointed UNOFFICIAL 1739.1-21 by the director of the department, and shall consist of: (1) The department's pharmacy consultant or medical consultant or both, shall serve as the drug use review coordinator(s); (2) Four persons licensed and actively engaged in the practice of medicine in the state; (3) Four persons licensed and actively practicing pharmacy in the state; and (4) One person actively practicing as a medical service representative in the state. (b) The term of each drug use review board member shall be three years and overlapped in such a way that expiration of terms shall not cause a total membership change. (c) A quorum shall consist of five board members; at least one of the five must be a physician or pharmacist. (d) The duties of the advisory drug use review board shall be to: (1) Meet when called by the chairperson; (2) Develop, review, and adapt criteria and standards for prospective and retrospective drug use review; (3) Make policy recommendations to the Hawaii medical assistance program in respect to confidentiality of patient related data, and all aspects of the drug use review program; (4) Decide on and monitor educational programs and interventions deemed appropriate based on potential therapeutic problems identified through the program; and (5) Determine the content and mix of educational programs and interventions for practitioners, designed to enhance the clinical appropriateness and cost effective use of prescription drugs with primary emphasis on therapeutic outcomes and quality of care. (e) The actions of the drug use review board shall be: (1) Subject to the approval of the department; (2) Remain confidential within the department; and (3) Be communicated to the specific providers affected. [Eff 10/26/01 ] (Auth: HRS §346-14; P.L. 101-508) (Imp: 42 C.F.R. §§456.1, 456.3) UNOFFICIAL 1739.1-22 §17-1739.1-14 Medical payment involving third party liability. (a) The liability of a third party for the cost of the medical services shall be treated as a resource applicable to the cost of needed medical services when: (1) It has been verified that a legal obligation actually exists; and (2) The amount of the obligation may be determined within thirty days from the time of the recipient's need for medical care. (b) No Medicaid payment may be made under a refund plan for that portion of cost for which a third party has been determined to be liable and reimbursement is forthcoming. An exception is Medicaid’s agreement with Medicare on durable medical equipment processing. (c) If a liability by an identified third party exists, the recipient shall be required to satisfy all conditions set forth by that third party to receive third party coverage, to the extent coverage is available, before Medicaid payment is allowed. (d) When the existence or extent of third party liability is in question, medical assistance payments may be made: (1) In part, if the recipient has excess income and other assets; or (2) For the entire cost of the medical services, if the recipient assigns to the department in writing, the third party payment; provided that where third party policy prohibits assignment of payment, the recipient shall, in writing, agree to refund the department upon being paid by the third party. [Eff 10/26/01; am 02/07/05] (Auth: HRS §346-59) (Imp: 42 C.F.R. §§433.135 through 433.154, 447.20)