|
|
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A BILL TO BE ENTITLED
|
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AN ACT
|
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relating to procedures for certain audits of pharmacists and |
|
pharmacies. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 843, Insurance Code, is amended by |
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adding Subchapter O to read as follows: |
|
SUBCHAPTER O. AUDITS OF PHARMACISTS AND PHARMACIES |
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Sec. 843.501. DEFINITIONS. In this subchapter: |
|
(1) "Auditor" means a health maintenance organization |
|
or a pharmacy benefit manager that provides pharmacy-related |
|
services for health maintenance organization enrollees that is |
|
performing an on-site audit or a desk audit of a pharmacist or |
|
pharmacy or another entity performing an on-site audit or a desk |
|
audit of a pharmacist or pharmacy on behalf of the organization or |
|
manager. |
|
(2) "Desk audit" means an audit conducted by an |
|
auditor at a location other than the location of the pharmacist or |
|
pharmacy. The term includes an audit performed at the auditor's |
|
offices during which the pharmacist or pharmacy provides requested |
|
documents for auditor review by hard copy or by microfiche, disk, or |
|
other electronic media. |
|
(3) "On-site audit" means an audit that is conducted |
|
at: |
|
(A) the location of the pharmacist or pharmacy; |
|
or |
|
(B) another location at which the records under |
|
review are stored. |
|
Sec. 843.503. AUDIT REQUIRING PROFESSIONAL JUDGMENT. An |
|
on-site audit or a desk audit involving a pharmacist's clinical or |
|
professional judgment must be conducted in consultation with a |
|
pharmacist licensed by the Texas State Board of Pharmacy. |
|
Sec. 843.504. ACCESS TO PHARMACY AREA. An auditor may not |
|
enter the pharmacy area unless escorted by the pharmacist-in-charge |
|
as defined by Section 551.003(29), Occupations Code. |
|
Sec. 843.505. VALIDATION USING CERTAIN RECORDS AUTHORIZED. |
|
A pharmacist or pharmacy that is being audited may: |
|
(1) validate a prescription, refill, or change in a |
|
prescription with a prescription that complies with rules adopted |
|
under Section 554.051, Occupations Code; and |
|
(2) validate the delivery of a prescription with a |
|
written record of a hospital, physician, or other authorized |
|
practitioner of the healing arts. |
|
Sec. 843.506. CALCULATION OF RECOUPMENT; USE OF |
|
EXTRAPOLATION PROHIBITED. (a) An auditor may not calculate the |
|
amount of a recoupment based on: |
|
(1) an absence of documentation the pharmacist or |
|
pharmacy is not required by law to maintain; or |
|
(2) an error that does not result in actual financial |
|
harm to the enrollee, health maintenance organization, or pharmacy |
|
benefit manager. |
|
(b) A health maintenance organization or pharmacy benefit |
|
manager may not require extrapolation audits as a condition of |
|
participation in a contract, network, or program for a pharmacist |
|
or pharmacy. |
|
(c) An auditor may not use extrapolation to complete an |
|
on-site audit or a desk audit of a pharmacist or pharmacy. |
|
Notwithstanding Subsection (a)(2), the amount of a recoupment must |
|
be based on the actual overpayment or underpayment and may not be |
|
based on an extrapolation. |
|
(d) An auditor may not include a dispensing fee amount in |
|
the calculation of an overpayment unless: |
|
(1) the fee was a duplicate charge; or |
|
(2) the prescription for which the fee was charged: |
|
(A) was not dispensed; or |
|
(B) was dispensed without the prescriber's |
|
authorization. |
|
Sec. 843.507. CLERICAL OR RECORDKEEPING ERROR. An |
|
unintentional clerical or recordkeeping error, such as a |
|
typographical error, scrivener's error, or computer error, found |
|
during an on-site audit or a desk audit: |
|
(1) is not prima facie evidence of fraud; and |
|
(2) may not be the basis of a recoupment from a |
|
pharmacist or pharmacy without proof of intent to commit fraud. |
|
Sec. 843.508. UNIFORM STANDARDS REQUIRED. An auditor must |
|
conduct an on-site audit or a desk audit of similarly situated |
|
pharmacists or pharmacies under the same audit standards. |
|
Sec. 843.509. ACCESS TO PREVIOUS AUDIT REPORTS. An auditor |
|
may have access to audit reports of a pharmacist or pharmacy that |
|
were prepared only for the health maintenance organization or |
|
pharmacy benefit manager for which the auditor is conducting an |
|
audit. |
|
Sec. 843.510. COMPENSATION OF AUDITOR. A health |
|
maintenance organization, pharmacy benefit manager, or other |
|
auditor may not base compensation paid to the individual or entity |
|
performing an on-site audit or a desk audit on a percentage of the |
|
amount the health maintenance organization, pharmacy benefit |
|
manager, or other auditor is entitled to recover as the result of |
|
the audit. |
|
Sec. 843.511. CONCLUSION OF AUDIT; SUMMARY; PRELIMINARY |
|
AUDIT REPORT. (a) At the conclusion of an on-site audit or a desk |
|
audit, the auditor shall: |
|
(1) provide to the pharmacist or pharmacy a summary of |
|
the audit findings; and |
|
(2) allow the pharmacist or pharmacy to respond to |
|
questions and alleged discrepancies, if any, and comment on and |
|
clarify the findings. |
|
(b) Not later than the 30th day after the date the audit is |
|
concluded, the auditor shall send by certified mail, return receipt |
|
requested, to the pharmacist or pharmacy a preliminary audit report |
|
stating the results of the audit, including explanations for and |
|
the amount of recoupment claimed. |
|
(c) The pharmacist or pharmacy may, by providing |
|
documentation or otherwise, challenge a result or remedy a |
|
discrepancy stated in the preliminary audit report not later than |
|
the 30th day after the date the pharmacist or pharmacy receives the |
|
report. |
|
Sec. 843.512. FINAL AUDIT REPORT. Not later than the 90th |
|
day after the date the pharmacist or pharmacy receives a |
|
preliminary audit report under Section 843.511, the auditor shall |
|
send by certified mail, return receipt requested, to the pharmacist |
|
or pharmacy a final audit report that states: |
|
(1) a summary of the pharmacist's or pharmacy's |
|
explanation and documentation, if any, submitted in response to the |
|
preliminary audit report; and |
|
(2) the audit results, including a description of all |
|
alleged discrepancies and explanations for and the amount of |
|
recoupments claimed after consideration of the pharmacist's or |
|
pharmacy's response to the preliminary audit report. |
|
Sec. 843.513. APPEAL OF FINAL AUDIT REPORT; AUDIT OUTCOME |
|
REPORT. (a) An auditor shall establish a process for a pharmacist |
|
or pharmacy to wholly or partly appeal a final audit report. |
|
(b) An auditor shall use the National Council for |
|
Prescription Drug Programs' data interchange standards for |
|
pharmacy claim submission to evaluate audited claims and appeals |
|
under the process established under Subsection (a). |
|
(c) On the date a final audit report is found wholly or |
|
partly unsubstantiated after an appeal under the process |
|
established under Subsection (a), the auditor shall reject the |
|
report, wholly or partly, as applicable. |
|
(d) Not later than the 30th day after the date an appeal |
|
under the process established under Subsection (a) is concluded, |
|
the auditor shall send by certified mail, return receipt requested, |
|
to the pharmacist or pharmacy an audit outcome report that |
|
includes: |
|
(1) a summary of the pharmacist's or pharmacy's |
|
arguments and documentation, if any, submitted in response to the |
|
final audit report; and |
|
(2) the audit results and recoupments claimed after |
|
consideration of the pharmacist's or pharmacy's response to the |
|
final audit report. |
|
Sec. 843.514. RECOUPMENT AND INTEREST CHARGED AFTER AUDIT. |
|
If an audit under this subchapter is conducted, the health |
|
maintenance organization or pharmacy benefit manager: |
|
(1) may recoup from the pharmacist or pharmacy an |
|
amount based only on a final audit report or, if appealed under the |
|
process established under Section 843.513(a), an audit outcome |
|
report; and |
|
(2) may not accrue or assess interest on an amount due |
|
until the later of the date the pharmacist or pharmacy receives the |
|
final audit report or, if appealed under the process established |
|
under Section 843.513(a), the date of the audit outcome report. |
|
Sec. 843.515. MEDIATION. (a) A pharmacist or pharmacy |
|
aggrieved by an audit outcome report may require an auditor to |
|
participate in mediation under Chapter 154, Civil Practice and |
|
Remedies Code. |
|
(b) The pharmacist or pharmacy must elect mediation and |
|
notify the auditor not later than the 30th day after the date the |
|
pharmacist or pharmacy receives the audit outcome report. The |
|
mediation must be completed not later than the 90th day after the |
|
date the pharmacist or pharmacy receives the audit outcome report. |
|
(c) The mediation must be conducted by a person qualified as |
|
an impartial third party under Section 154.052, Civil Practice and |
|
Remedies Code. |
|
Sec. 843.516. REMEDIES NOT EXCLUSIVE. This section may not |
|
be construed to waive a remedy at law available to a pharmacist or |
|
pharmacy. |
|
Sec. 843.517. WAIVER PROHIBITED. The provisions of this |
|
subchapter may not be waived, voided, or nullified by contract. |
|
Sec. 843.518. LEGISLATIVE DECLARATION. It is the intent of |
|
the legislature that the requirements contained in this subchapter |
|
regarding audit of claims to providers who are pharmacists or |
|
pharmacies apply to all health maintenance organizations and |
|
pharmacy benefit managers unless otherwise prohibited by federal |
|
law. |
|
SECTION 2. Section 843.3401, Insurance Code, is transferred |
|
to Subchapter O, Chapter 843, Insurance Code, as added by this Act, |
|
redesignated as Section 843.502, Insurance Code, and amended to |
|
read as follows: |
|
Sec. 843.502 [843.3401]. AUDIT OF PHARMACIST OR PHARMACY; |
|
NOTICE; GENERAL PROVISIONS. (a) An auditor [A health maintenance
|
|
organization or a pharmacy benefit manager that administers
|
|
pharmacy claims for the health maintenance organization may not use
|
|
extrapolation to complete the audit of a provider who is a
|
|
pharmacist or pharmacy.
A health maintenance organization may not
|
|
require extrapolation audits as a condition of participation in the
|
|
health maintenance organization's contract, network, or program
|
|
for a provider who is a pharmacist or pharmacy.
|
|
[(b)
A health maintenance organization or a pharmacy
|
|
benefit manager that administers pharmacy claims for the health
|
|
maintenance organization] that performs an on-site audit or a desk |
|
audit under this chapter of a provider who is a pharmacist or |
|
pharmacy shall provide the provider reasonable notice of the audit |
|
and accommodate the provider's schedule to the greatest extent |
|
possible. The notice required under this subsection must be in |
|
writing and must be sent by certified mail to the provider not later |
|
than the 15th day before the date on which the on-site audit is |
|
scheduled to occur. |
|
(b) Not later than the seventh day after the date a |
|
pharmacist or pharmacy receives notice under Subsection (a), the |
|
pharmacist or pharmacy may reschedule an on-site audit or a desk |
|
audit to a date not later than the 14th day after the date the audit |
|
is initially scheduled. On agreement of the pharmacist or pharmacy |
|
and the auditor, the audit may be rescheduled to a date after the |
|
14th day after the date the audit is initially scheduled. |
|
(c) Unless the pharmacist or pharmacy consents in writing, |
|
an auditor may not schedule or have an on-site audit or a desk audit |
|
conducted: |
|
(1) before the 30th day after the date the pharmacist |
|
or pharmacy receives notice under Subsection (a); |
|
(2) more than once annually; or |
|
(3) during the first seven calendar days of a month. |
|
(d) A pharmacist or pharmacy may be required to submit |
|
documents in response to a desk audit not earlier than the 30th day |
|
after the date the auditor requests the documents. |
|
(e) A contract between a pharmacist or pharmacy and a health |
|
maintenance organization or a pharmacy benefit manager must state |
|
detailed audit procedures. If a health maintenance organization or |
|
pharmacy benefit manager proposes a change to the audit procedures |
|
for an on-site audit or a desk audit, the organization or manager |
|
must notify the pharmacist or pharmacy in writing of a change in an |
|
audit procedure not later than the 60th day before the effective |
|
date of the change. |
|
(f) The list of the claims subject to audit must be provided |
|
in the notice under Subsection (a) to the pharmacist or pharmacy and |
|
may identify the claims only by the prescription numbers or a date |
|
range for prescriptions subject to the audit. |
|
(g) If the auditor: |
|
(1) in an on-site audit or a desk audit applies random |
|
sampling procedures to select claims for audit, the sample size may |
|
not be greater than 50 individual prescription claims; or |
|
(2) conducts an on-site audit or a desk audit related |
|
to a specific issue, the number of individual prescription claims |
|
subject to the audit may not be greater than 50 and, notwithstanding |
|
Subsection (f), may be identified only by prescription number. |
|
(h) After an audit is initiated, a pharmacist or pharmacy |
|
may electronically resubmit a disputed claim if the deadline for |
|
submission of a claim under Section 843.337 has not expired. |
|
SECTION 3. Chapter 1301, Insurance Code, is amended by |
|
adding Subchapter F to read as follows: |
|
SUBCHAPTER F. AUDITS OF PHARMACISTS AND PHARMACIES |
|
Sec. 1301.251. DEFINITIONS. In this subchapter: |
|
(1) "Auditor" means an insurer or a pharmacy benefit |
|
manager that provides pharmacy-related services for the insurer's |
|
insureds that is performing an on-site audit or a desk audit of a |
|
preferred provider that is a pharmacist or pharmacy or another |
|
entity performing an on-site audit or a desk audit of a preferred |
|
provider that is a pharmacist or pharmacy on behalf of the insurer |
|
or manager. |
|
(2) "Desk audit" means an audit conducted by an |
|
auditor at a location other than the location of the pharmacist or |
|
pharmacy. The term includes an audit performed at the auditor's |
|
offices during which the pharmacist or pharmacy provides requested |
|
documents for auditor review by hard copy or by microfiche, disk, or |
|
other electronic media. |
|
(3) "On-site audit" means an audit that is conducted |
|
at: |
|
(A) the location of the pharmacist or pharmacy; |
|
or |
|
(B) another location at which the records under |
|
review are stored. |
|
Sec. 1301.253. AUDIT REQUIRING PROFESSIONAL JUDGMENT. An |
|
on-site audit or a desk audit involving a pharmacist's clinical or |
|
professional judgment must be conducted in consultation with a |
|
pharmacist licensed by the Texas State Board of Pharmacy. |
|
Sec. 1301.254. ACCESS TO PHARMACY AREA. An auditor may not |
|
enter the pharmacy area unless escorted by the pharmacist-in-charge |
|
as defined by Section 551.003(29), Occupations Code. |
|
Sec. 1301.255. VALIDATION USING CERTAIN RECORDS |
|
AUTHORIZED. A pharmacist or pharmacy that is being audited may: |
|
(1) validate a prescription, refill, or change in a |
|
prescription with a prescription that complies with rules adopted |
|
under Section 554.051, Occupations Code; and |
|
(2) validate the delivery of a prescription with a |
|
written record of a hospital, physician, or other authorized |
|
practitioner of the healing arts. |
|
Sec. 1301.256. CALCULATION OF RECOUPMENT; EXTRAPOLATION |
|
PROHIBITED. (a) An auditor may not calculate the amount of a |
|
recoupment based on: |
|
(1) an absence of documentation the pharmacist or |
|
pharmacy is not required by law to maintain; or |
|
(2) an error that does not result in actual financial |
|
harm to the insured, insurer, or pharmacy benefit manager. |
|
(b) An insurer or pharmacy benefit manager may not require |
|
extrapolation audits as a condition of participation in a contract, |
|
network, or program for a pharmacist or pharmacy. |
|
(c) An auditor may not use extrapolation to complete an |
|
on-site audit or a desk audit of a pharmacist or pharmacy. |
|
Notwithstanding Subsection (a)(2), the amount of a recoupment must |
|
be based on the actual overpayment or underpayment and may not be |
|
based on an extrapolation. |
|
(d) An auditor may not include a dispensing fee amount in |
|
the calculation of an overpayment unless: |
|
(1) the fee was a duplicate charge; or |
|
(2) the prescription for which the fee was charged: |
|
(A) was not dispensed; or |
|
(B) was dispensed without the prescriber's |
|
authorization. |
|
Sec. 1301.257. CLERICAL OR RECORDKEEPING ERROR. An |
|
unintentional clerical or recordkeeping error, such as a |
|
typographical error, scrivener's error, or computer error, found |
|
during an on-site audit or a desk audit: |
|
(1) is not prima facie evidence of fraud; and |
|
(2) may not be the basis of a recoupment from a |
|
pharmacist or pharmacy without proof of intent to commit fraud. |
|
Sec. 1301.258. UNIFORM STANDARDS REQUIRED. An auditor must |
|
conduct an on-site audit or a desk audit of similarly situated |
|
pharmacists or pharmacies under the same audit standards. |
|
Sec. 1301.259. ACCESS TO PREVIOUS AUDIT REPORTS. An |
|
auditor may have access to audit reports of a pharmacist or |
|
pharmacy that were prepared only for the insurer or pharmacy |
|
benefit manager for which the auditor is conducting an audit. |
|
Sec. 1301.260. COMPENSATION OF AUDITOR. An insurer, |
|
pharmacy benefit manager, or other auditor may not base |
|
compensation paid to the individual or entity performing an on-site |
|
audit or a desk audit on a percentage of the amount the insurer, |
|
pharmacy benefit manager, or other auditor is entitled to recover |
|
as the result of the audit. |
|
Sec. 1301.261. CONCLUSION OF AUDIT; SUMMARY; PRELIMINARY |
|
AUDIT REPORT. (a) At the conclusion of an on-site audit or a desk |
|
audit, the auditor shall: |
|
(1) provide to the pharmacist or pharmacy a summary of |
|
the audit findings; and |
|
(2) allow the pharmacist or pharmacy to respond to |
|
questions and alleged discrepancies, if any, and comment on and |
|
clarify the findings. |
|
(b) Not later than the 30th day after the date the audit is |
|
concluded, the auditor shall send by certified mail, return receipt |
|
requested, to the pharmacist or pharmacy a preliminary audit report |
|
stating the results of the audit, including explanations for and |
|
the amount of recoupment claimed. |
|
(c) The pharmacist or pharmacy may, by providing |
|
documentation or otherwise, challenge a result or remedy a |
|
discrepancy stated in the preliminary audit report not later than |
|
the 30th day after the date the pharmacist or pharmacy receives the |
|
report. |
|
Sec. 1301.262. FINAL AUDIT REPORT. Not later than the 90th |
|
day after the date the pharmacist or pharmacy receives a |
|
preliminary audit report under Section 1301.261, the auditor shall |
|
send by certified mail, return receipt requested, to the pharmacist |
|
or pharmacy a final audit report that states: |
|
(1) a summary of the pharmacist's or pharmacy's |
|
explanation and documentation, if any, submitted in response to the |
|
preliminary audit report; and |
|
(2) the audit results, including a description of all |
|
alleged discrepancies and explanations for and the amount of |
|
recoupments claimed after consideration of the pharmacist's or |
|
pharmacy's response to the preliminary audit report. |
|
Sec. 1301.263. APPEAL OF FINAL AUDIT REPORT; AUDIT OUTCOME |
|
REPORT. (a) An auditor shall establish a process for a pharmacist |
|
or pharmacy to wholly or partly appeal a final audit report. |
|
(b) An auditor shall use the National Council for |
|
Prescription Drug Programs' data interchange standards for |
|
pharmacy claim submission to evaluate audited claims and appeals |
|
under the process established under Subsection (a). |
|
(c) On the date a final audit report is found wholly or |
|
partly unsubstantiated after an appeal under the process |
|
established under Subsection (a), the auditor shall reject the |
|
report, wholly or partly, as applicable. |
|
(d) Not later than the 30th day after the date an appeal |
|
under the process established under Subsection (a) is concluded, |
|
the auditor shall send by certified mail, return receipt requested, |
|
to the pharmacist or pharmacy an audit outcome report that |
|
includes: |
|
(1) a summary of the pharmacist's or pharmacy's |
|
arguments and documentation, if any, submitted in response to the |
|
final audit report; and |
|
(2) the audit results and recoupments claimed after |
|
consideration of the pharmacist's or pharmacy's response to the |
|
final audit report. |
|
Sec. 1301.264. RECOUPMENT AND INTEREST CHARGED AFTER AUDIT. |
|
If an audit under this subchapter is conducted, the insurer or |
|
pharmacy benefit manager: |
|
(1) may recoup from the pharmacist or pharmacy an |
|
amount based only on a final audit report or, if appealed under the |
|
process established under Section 1301.263(a), an audit outcome |
|
report; and |
|
(2) may not accrue or assess interest on an amount due |
|
until the later of the date the pharmacist or pharmacy receives the |
|
final audit report or, if appealed under the process established |
|
under Section 1301.263(a), the date of the audit outcome report. |
|
Sec. 1301.265. MEDIATION. (a) A pharmacist or pharmacy |
|
aggrieved by an audit outcome report may require an auditor to |
|
participate in mediation under Chapter 154, Civil Practice and |
|
Remedies Code. |
|
(b) The pharmacist or pharmacy must elect mediation and |
|
notify the auditor not later than the 30th day after the date the |
|
pharmacist or pharmacy receives the audit outcome report. The |
|
mediation must be completed not later than the 90th day after the |
|
date the pharmacist or pharmacy receives the audit outcome report. |
|
(c) The mediation must be conducted by a person qualified as |
|
an impartial third party under Section 154.052, Civil Practice and |
|
Remedies Code. |
|
Sec. 1301.266. REMEDIES NOT EXCLUSIVE. This section may |
|
not be construed to waive a remedy at law available to a pharmacist |
|
or pharmacy. |
|
Sec. 1301.267. WAIVER PROHIBITED. The provisions of this |
|
subchapter may not be waived, voided, or nullified by contract. |
|
Sec. 1301.268. LEGISLATIVE DECLARATION. It is the intent |
|
of the legislature that the requirements contained in this |
|
subchapter regarding audit of claims to preferred providers who are |
|
pharmacists or pharmacies apply to all insurers and pharmacy |
|
benefit managers unless otherwise prohibited by federal law. |
|
SECTION 4. Section 1301.1041, Insurance Code, is |
|
transferred to Subchapter F, Chapter 1301, Insurance Code, as added |
|
by this Act, redesignated as Section 1301.252, Insurance Code, and |
|
amended to read as follows: |
|
Sec. 1301.252 [1301.1041]. AUDIT OF PHARMACIST OR |
|
PHARMACY; NOTICE; GENERAL PROVISIONS. (a) An auditor [insurer or
|
|
a pharmacy benefit manager that administers pharmacy claims for the
|
|
insurer may not use extrapolation to complete the audit of a
|
|
preferred provider that is a pharmacist or pharmacy.
An insurer
|
|
may not require extrapolation audits as a condition of
|
|
participation in the insurer's contract, network, or program for a
|
|
preferred provider that is a pharmacist or pharmacy.
|
|
[(b)
An insurer or a pharmacy benefit manager that
|
|
administers pharmacy claims for the insurer] that performs an |
|
on-site audit or a desk audit of a preferred provider who is a |
|
pharmacist or pharmacy shall provide the provider reasonable notice |
|
of the audit and accommodate the provider's schedule to the |
|
greatest extent possible. The notice required under this |
|
subsection must be in writing and must be sent by certified mail to |
|
the preferred provider not later than the 15th day before the date |
|
on which the on-site audit is scheduled to occur. |
|
(b) Not later than the seventh day after the date a |
|
pharmacist or pharmacy receives notice under Subsection (a), the |
|
pharmacist or pharmacy may reschedule an on-site audit or a desk |
|
audit to a date not later than the 14th day after the date the audit |
|
is initially scheduled. On agreement of the pharmacist or pharmacy |
|
and the auditor, the audit may be rescheduled to a date after the |
|
14th day after the date the audit is initially scheduled. |
|
(c) Unless the pharmacist or pharmacy consents in writing, |
|
an auditor may not schedule or have an on-site audit or a desk audit |
|
conducted: |
|
(1) before the 30th day after the date the pharmacist |
|
or pharmacy receives notice under Subsection (a); |
|
(2) more than once annually; or |
|
(3) during the first seven calendar days of a month. |
|
(d) A pharmacist or pharmacy may be required to submit |
|
documents in response to a desk audit not earlier than the 30th day |
|
after the date the auditor requests the documents. |
|
(e) A contract between a pharmacist or pharmacy and an |
|
insurer or a pharmacy benefit manager must state detailed audit |
|
procedures. If an insurer or pharmacy benefit manager proposes a |
|
change to the audit procedures for an on-site audit or a desk audit, |
|
the insurer or pharmacy benefit manager must notify the pharmacist |
|
or pharmacy in writing of a change in an audit procedure not later |
|
than the 60th day before the effective date of the change. |
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(f) The list of the claims subject to audit must be provided |
|
in the notice under Subsection (a) to the pharmacist or pharmacy and |
|
may identify the claims only by the prescription numbers or a date |
|
range for prescriptions subject to the audit. |
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(g) If the auditor: |
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(1) in an on-site audit or a desk audit applies random |
|
sampling procedures to select claims for audit, the sample size may |
|
not be greater than 50 individual prescription claims; or |
|
(2) conducts an on-site audit or a desk audit related |
|
to a specific issue, the number of individual prescription claims |
|
subject to the audit may not be greater than 50 and, notwithstanding |
|
Subsection (f), may be identified only by prescription number. |
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(h) After an audit is initiated, a pharmacist or pharmacy |
|
may electronically resubmit a disputed claim if the deadline for |
|
submission of a claim under Section 1301.102 has not expired. |
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SECTION 5. The changes in law made by this Act apply only to |
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contracts between a pharmacist or pharmacy and a health maintenance |
|
organization, an insurer, or a pharmacy benefit manager executed or |
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renewed, and audits conducted under those contracts, on or after |
|
the effective date of this Act. A contract entered into or renewed, |
|
and audits conducted under those contracts, before the effective |
|
date of this Act are governed by the law in effect immediately |
|
before the effective date of this Act, and that law is continued in |
|
effect for that purpose. |
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SECTION 6. This Act takes effect September 1, 2013. |