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2026.40 - Provider Bulletin - Documentation Required for Override of Claims Rejected for ProDUR
Connecticut Medicaid (HUSKY Health)·CT · Pharmacy·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
Aug 1, 2026
Summary
Connecticut Medicaid (CMAP) now requires pharmacy providers to maintain contemporaneous, detailed documentation whenever they override a 'major' ProDUR (Prospective Drug Utilization Review) alert rejection on a paid claim. Documentation must include clinical justification, the intervention taken, contact information and authorization details from the prescriber/patient/other source consulted, and the pharmacist's name/initials. Failure to provide this documentation upon audit will result in claim recoupment by the state.
Action Required
Effective immediately: (1) Pharmacy Operations: Establish mandatory documentation protocols for all ProDUR override scenarios. Update pharmacy software or implement paper-based systems to capture and store: clinical justification, intervention codes (M0, P0, R0), prescriber contact details with date/time of authorization, patient consultation outcomes, and pharmacist identifier. (2) Pharmacy Staff Training: Train all pharmacists and pharmacy technicians that override documentation must include specific details—'OK per MD' or rubber stamps are insufficient without supporting information. (3) System Configuration: Confirm with pharmacy software vendor that electronic note fields are date/time stamped at creation and cannot be backdated or modified. Obtain vendor attestation in writing and maintain on file. (4) Records Management: Establish 5-year retention protocol for all override documentation (written, electronic, or hybrid). Ensure documentation is readily retrievable for DSS audit requests. (5) Audit Preparation: Create an audit trail log demonstrating compliance. Non-compliance will trigger recoupment of paid claim amounts during state Medicaid audit.