CMS Drug Utilization Review

$79 / year

This dataset contains information on labelers and products in the Medicaid Drug Utilization Review Program as collected through the Newly Revised Medicaid Drug Utilization Review Annual Report Survey released in 2014, regarding prescriptions and reimbursements. The DUR Annual Report Survey included since 2014 new sections on fraud, waste and abuse, Prescription Drug Monitoring Program and state Managed Care Organizations.

Complexity

The Medicaid Drug Utilization Review (DUR) Program promotes patient safety through state-administered utilization management tools and systems that interface with CMS’ Medicaid Management Information Systems (MMIS). Medicaid DUR is a two-phase process that is conducted by the Medicaid state agencies. In the first phase (prospective DUR) the state’s Medicaid agency’s electronic monitoring system screens prescription drug claims to identify problems such as therapeutic duplication, drug-disease contraindications, incorrect dosage or duration of treatment, drug allergy and clinical misuse or abuse. The second phase (retrospective DUR) involves ongoing and periodic examination of claims data to identify patterns of fraud, abuse, gross overuse, or medically unnecessary care and implements corrective action when needed.

On an annual basis, states are required to report on their state’s prescribing habits, cost savings generated from their DUR programs and their program’s operations, including the adoption of new innovative DUR practices via the Medicaid Drug Utilization Review Annual Report Survey.

Date Created

2011

Last Modified

2015

Version

2015

Update Frequency

Annual

Temporal Coverage

2015

Spatial Coverage

United States

Source

John Snow Labs => Centers for Medicare & Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

Centers for Medicare & Medicaid services, C.M.S. (2016). Medicaid.gov. Retrieved 2 March, 2016.

Keywords

CMS Drug Utilization, DUR Annual Drug Report, Prescription Drug Monitoring, Managed Care Organizations, Medicare Utilization Review, Medicaid Drug Utilization Review, CMS Annual Report Survey, Utilization Management, CMS Drug Reports

Other Titles

Drug Utilization Annual Report, Drug Utilization Survey, National Summary State Drug

Name Description Type Constraints
Record_IDThe FFSU (Fee-for-Service Utilization) Record ID indicates that the information for this NDC represents a Fee-for-Service Utilization record. The MCOU (Managed Care Organization Utilization) Record ID indicates that the information for this NDC represents a Managed Care Organization Utilization record.string-
Labeler_CodeFirst segment of National Drug Code (NDC1) that identifies the manufacturer, labeler, relabeler, packager, repackager or distributor of the drug.integerlevel : Nominal
Product_CodeSecond segment of National Drug Code (NDC2)integerlevel : Nominal
Package_SizeThird segment of National Drug Code (NDC3)integerlevel : Nominal
Period_CoveredCalendar year and quarter covered by data. Values: 20151 = January, 1 – March 31, 20152 = April 1 – June 30, 20153 = July 1 – September 30, 20154 = October 1 – December 31string-
Product_FDA_Name(Abbreviated) – First 10 characters of product name as approved by the FDA listing formstring-
Units_Reimbursed_USDThe total number of units (based on Unit Type) of the drug (11-digit NDC level) reimbursed by the state during the period covered.number-
No_PrescriptionsThe number of prescriptions reimbursed (by the Medicaid Program ONLY) to pharmacists for the (11-digit NDC) drug for the period covered.integerlevel : Ratio
Total_ReimbursedThe total amount reimbursed by both Medicaid and non-Medicaid entities to pharmacies for the (11-digit NDC) drug in the period covered (two below fields added together). This total is not reduced or affected by Medicaid rebates paid to the state. This amount represents both the Federal and State Reimbursement and is inclusive of dispensing fees.number-
Medicaid_ReimbursedThe amount reimbursed (by the Medicaid Program Only) to pharmacies for the (11-digit NDC) drug in the period covered.number-
Non_Medicaid_Amount_ReimbursedThe amount reimbursed (by non-Medicaid entities) to pharmacies for the (11-digit NDC) drug in the period covered. The Non-Medicaid Amount Reimbursed includes any reimbursement amount for which the state is not eligible for Federal Matching Funds.number-
Record_IDLabeler_CodeProduct_CodePackage_SizePeriod_CoveredProduct_FDA_NameUnits_Reimbursed_USDNo_PrescriptionsTotal_ReimbursedMedicaid_ReimbursedNon_Medicaid_Amount_Reimbursed
MCOU33804492015311000
MCOU56175752015331000
MCOU71481132015211000
FFSU522730201511118180
MCOU548005162015321000
MCOU143987512015251000
MCOU264800002015121000
MCOU338125502015321000
MCOU409613922015332000
FFSU9303220152110.70.70