Ala. Admin. Code r. 560-X-16-.25

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-16-.25 - Retrospective DUR

(1) The retrospective DUR Program reviews, analyzes and interprets patterns of recipient drug usage by applying criteria and standards, developed by the DUR Board, against claims data through periodic examination to identify patterns of fraud and abuse, gross overuse, and inappropriate or medically unnecessary care. Cases of possible fraud and/or abuse shall be referred to the Medicaid Program Integrity Division.

Author:

Emergency rule: Effective July 1, 1993. Permanent rule effective October 14, 1993.

Statutory Authority: State Plan, Page 74a; Title XIX, Social Security Act; 42 CFR Section 440.120; Public Law 101-508.