DUR codes: documenting the intervention.

At the counter: a DUR reject identifies a clinical edit. When the payer's instructions call for them, the DUR/PPS claim request can record the returned conflict in Reason for Service (439-E4), the professional service in 440-E5, and the prescription outcome in 441-E6. Complete and document the intervention before transmitting the payer's accepted fields and values.

The reject-code reference explains why reject 88 fired. This guide covers the claim-request fields, published payer combinations, refill-too-soon mechanisms, and documentation to retain.

What is a DUR reject, and how is it different from reject 88?

Two segments, running in opposite directions.

The payer's edit fires and comes back in the response DUR/PPS segment: a response code counter (567-J6), the Reason for Service Code that identifies the conflict (439-E4), a clinical significance code (528-FS), the previous fill date and quantity (530-FU, 531-FV), a database indicator (532-FW), and free-text fields (544-FY, 570-NS) that often carry the other pharmacy's or prescriber's contact details on an early-fill edit.

Your answer goes out in the request DUR/PPS segment: a code counter (473-7E) and the triplet, 439-E4, 440-E5, 441-E6, plus, where used, level of effort (474-8E) and co-agent identification (475-J9 and 476-H6).

New York's ProDUR manual states that the Reason for Service must match the returned Drug Conflict Code and that a corresponding Result of Service must be entered. For that payer, 439-E4 reports the returned conflict rather than substituting a different reason code.

The full NCPDP External Code List is licensed. New York's companion guide marks 439-E4 "all code set values supported" and directs providers to that list. The state reference below compares only the public subsets and processing rules individual programs publish. When two manuals conflict, the current manual for the claim's payer controls.

Reason for Service Code (439-E4): what the payer is telling you

The public code set is not a state-by-state formulary. The same NCPDP value can be accepted, informational, restricted to a particular edit, or omitted from a state program's public instructions. This directory includes all 50 state Medicaid programs, using public fee-for-service material where that program publishes it and explaining source limitations inside each state's entry. It is not a nationwide rulebook: managed-care plans can differ inside the same state, and several states do not publish a state-specific value list.

Two codes change meaning by field. Louisiana uses MR for "Poly-Prescriber Detected" in 439-E4, while MR means "Medication Review" in 440-E5. Read the field before interpreting the value.

Professional Service Code (440-E5): what you did about it

CMS describes the three DUR fields as independent standard data elements. NCPDP-aligned references define R0 as pharmacist consulted other source, while Nevada's manual prints physician. Because those publications conflict, verify the active payer instruction before submission and do not assume the terms are interchangeable.

Result of Service Code (441-E6): what happened to the prescription

NCPDP-aligned references define 2B as "Not Filled, Directions Clarified." Louisiana's manual prints "Prescription Filled, Directions Clarified." Because those publications conflict, verify the active payer instruction before submitting 2B and do not assume the two outcomes are interchangeable.

Which combinations do payers publish?

The accepted combination is payer-specific.

Louisiana prescribes the triplet exactly. Its vendor specifications state that "AT, DD, HD, NN, MX and TD Reasons for Service require Professional Service Code = M0" and that for those same conflicts the "Result of Service Code (DUR Outcome) = 1G." For ID and ER, the accepted professional service codes widen to M0, P0 or R0, and the outcome codes to essentially the full list.

For those six conflicts, Louisiana's published accepted combination is the conflict code, plus M0, plus 1G: prescriber consulted and filled with prescriber approval. The triplet records the intervention and outcome; it does not replace the clinical work.

New York's companion guide states that the Professional Service Code is ignored during claim processing. Reason for Service and Result of Service still control the submitted response.

Mississippi requires both the Professional Service and Result of Service fields whenever a DUR alert is present, without prescribing pairings.

California requires every rejecting conflict to be addressed independently. Informational messages do not require resolution. Its public guidance also publishes special-purpose combinations beyond clinical overrides: PH + MA + 3N in its vaccine-billing section (with a COVID-19 exception), TP with a documented consultation and filled outcome for a payer question, and additional Professional Service values CC, DE, and DP for opioid MME alerts.

North Carolina requires a separate response to every alert. Its effective May 2, 2026 matrix publishes M0, P0, R0, 00, or blank for ER, DD, TD, HD, and PG, with a bounded result list. Early-refill overrides add a situation-specific Submission Clarification Code and narrow further for opioids and benzodiazepines.

Indiana requires the submitted reason to match a conflict returned on the rejected claim. The same resubmission also needs a Professional Service and Result of Service. Alabama, by contrast, says only the first occurrence of the three fields will be used in processing. Because these multi-alert rules differ, use the current payer's instructions for the claim.

Some edits require another path. Utah states that claims exceeding CDC-recommended limits on quantity, therapeutic duplication and morphine equivalent dose "cannot be overridden at the pharmacy and require prior authorization to be considered for review." Wisconsin routes early-refill overrides through a policy override center by phone. Colorado requires a prior authorization request obtained from its pharmacy support center. Nevada states that "override codes must be entered each time error occurs"; the override does not persist on the prescription.

How do you override a refill too soon?

Several payer guides use Submission Clarification Code, field 420-DK, or a help-desk process instead of the DUR triplet.

Two cautions. The cited payer guides do not publish a universal clarification code for stolen medication; Nevada publishes 04 for a lost prescription. SCC 14 is a long-term-care short-fill and leave-of-absence code, not a general early-refill override.

The same clinical situation arrives under different codes at different payers. Nevada returns reject 88 for a non-controlled early refill, while Utah surfaces refill-too-soon as reject 79. Published thresholds also vary: 75% in New York, 75% for non-scheduled and 85% for CII–CV in Colorado, 80% and 90% in Nevada, and a sliding 65/80/85% by days supply in Wisconsin. The number submitted on the previous fill therefore matters; the days-supply guide shows the arithmetic.

What is the DUR code for "not opioid naive"?

There is no universal code. CMS leaves the override mechanism to each Part D sponsor.

CMS expects Part D sponsors to implement opioid safety edits for non-exempt beneficiaries, while preserving pharmacist clinical judgment and access to medically necessary therapy. The current thresholds appear in CMS's CY 2027 submission instructions dated July 2, 2026:

• Opioid-naive initial fill: limited to a seven-day supply or less. A hard edit, required of all sponsors.
• Care coordination edit: triggers when cumulative morphine milligram equivalents per day reach or exceed 90 MME. A soft edit, required; CMS recommends a minimum threshold of two or more opioid prescribers.
• MME hard edit at 200 MME per day: optional for sponsors.
• Soft edits for duplicative long-acting opioid therapy and for concurrent opioid and benzodiazepine use.

CMS does not publish one universal override code. It directs sponsors either to provide appropriate override codes or to make a real-time help-desk override available when automated codes are not supported. Use the plan's payer sheet or help desk.

CMS is also explicit about what has to accompany it: "consult with the enrollee's prescriber to confirm intent... document the discussion and submit the appropriate override code," with the documentation including date, time, prescriber name and a brief note. CMS's FAQ adds two practical allowances, a repeat consultation is generally not needed if one was done recently, and consulting office staff or a covering physician is acceptable. It also states that access to medications for opioid use disorder, such as buprenorphine, should not be impacted.

A published counterexample shows how differently a non-Part-D payer can handle the identical edit: MassHealth's opioid-naive seven-day first-fill restriction rejects as "AG to Days' supply limitation for product/service" and is cleared with submission clarification code 10, meets plan limitations, not a DUR triplet at all.

ProDUR and RetroDUR

Two different programs that share a name. Medicaid.gov defines prospective DUR as evaluating planned therapy before dispensing, the real-time edits in this article. Retrospective DUR happens after the patient receives the medication, reviewing claims data for patterns and following up with educational interventions to prescribers, pharmacists or beneficiaries. Both sit under section 1927(g) of the Social Security Act, in place since 1993, with regulations at 42 CFR 456.700 through 456.725.

New York's manual gives a clear picture of the ProDUR calculation. Therapeutic duplication "checks the therapeutic class of the new drug against the classes of the member's current, active drugs already dispensed." Drug-drug "matches the new drug against the member's current, active drugs to identify clinically relevant interactions." Drug overuse "determines at the time of refill that less than 75% of the previously dispensed amount, based on the previously dispensed supply, has been used."

Is submitting a DUR override an audit risk?

State programs may track override activity, and the documentation requirement is explicit.

Utah's provider manual states that "the DUR hard edit will require pharmacist input of an NCPDP override code, documenting the intervention made, before the claim will process." New York is more specific about form: "pharmacies must document the reason for the override," and recommends either writing the date, reason and pharmacist's signature or initials on the back of the prescription, or storing the reason electronically in the patient profile for the specific prescription filled. Louisiana requires that "the reason for service code, professional service code and result of service code must also be documented on the hardcopy prescription," and for early narcotic fills, that the pharmacist document, after consulting the prescriber, why the prescriber required the patient to receive the analgesic early.

CMS's national Medicaid DUR survey asks states whether they receive reports on individual pharmacy providers' override activity and whether they follow up with providers who routinely override. That establishes federal collection of state practices, not a claim that CMS directly tracks every pharmacy.

The published rules require a documented intervention, and override patterns are monitored. Codes 440-E5 and 441-E6 represent the professional service performed and the prescription outcome. Submit only values supported by the clinical record.

What to document before resubmitting

• The conflict code returned by the payer and the clinical issue reviewed.
• The date, time and pharmacist who performed the intervention.
• The prescriber, patient or other source contacted, plus the decision reached.
• The prescription outcome represented by field 441-E6.
• The payer sheet or help-desk instruction supporting the transmitted combination.