T41CH66
Title 41 > T41CH66
Sections (5)
41-6601
TITLE 41 INSURANCE CHAPTER 66 FAIR PHARMACY AUDITS ACT 41-6601. SHORT TITLE. This chapter shall be known and may be cited as the Fair Pharmacy Audits Act. History: [41-6601, added 2023, ch. 233, sec. 1, p. 719.]
41-6602
TITLE 41 INSURANCE CHAPTER 66 FAIR PHARMACY AUDITS ACT 41-6602. purpose and applicability. (1) The purpose of this chapter is to establish minimum and uniform standards and criteria for the audit of pharmacies. (2) The provisions of this chapter shall apply to any audit of a pharmacy conducted on or after July 1, 2023, unless: (a) Contrary provisions for a specific type of audit are provided in federal or state law, rule, or procedure; (b) The audit relates to medicaid payments; (c) The audit is an investigative audit based on reasonable suspicion of willful misrepresentation, abuse, waste, or fraud; or (d) The audit is a financial examination conducted by a certified public accountant according to generally accepted auditing standards. History: [41-6602, added 2023, ch. 233, sec. 1, p. 719.]
41-6603
TITLE 41 INSURANCE CHAPTER 66 FAIR PHARMACY AUDITS ACT 41-6603. requirements and prohibitions for pharmacy audits. (1) Any person or entity conducting an audit of a pharmacy shall: (a) If performing the audit pursuant to a contract, identify and specifically describe the contract provisions authorizing the audit, including provisions relating to audit appeals. No contract may require prescription claim documentation or recordkeeping requirements that exceed requirements set forth in applicable federal or state law, regulation, or rule; (b) Give written notice to the pharmacy and the pharmacy’s contracting agent at least fourteen (14) days prior to conducting the on-site audit. For purposes of this subsection, the term audit means an audit conducted on behalf of an auditing entity of any records of a pharmacy for drugs dispensed by a pharmacy to a covered individual. The pharmacy shall have the opportunity to reschedule any on-site audit no more than seven (7) days from the date designated on the original audit notification; (c) Not interfere with the delivery of pharmacist services to a patient and use every reasonable effort to minimize inconvenience and disruption to pharmacy operations during the on-site audit process; (d) Conduct any audit involving clinical or professional judgment by means of or in consultation with a licensed pharmacist; (e) Prior to leaving the pharmacy after the on-site portion of the pharmacy audit, provide to the pharmacy a complete list of pharmacy records reviewed; (f) Not subject a pharmacy to a charge-back or recoupment for a clerical or recordkeeping error, such as a typographical error, scrivener’s error, or computer error, including but not limited to a miscalculated day supply, an incorrectly billed prescription written date, or an incorrect prescription origin code, unless the error resulted in overpayment to the pharmacy. Prior to payment of the claim, the pharmacy shall have the right to submit amended claims electronically to correct clerical or recordkeeping errors in lieu of recoupment. A person shall not be subject to criminal penalties for errors described in this paragraph without proof of the intent required for conviction of the applicable crime; (g) Limit any fee, charge-back, recoupment, or other adjustment to the actual overpayment associated with the dispensed product or portion of the dispensed product or the actual underpayment or overpayment as set forth in this subsection; (h) Permit a pharmacy to use any valid prescription, including computerized patterned medical records or the records of a hospital, physician, or other authorized health care practitioner for drugs or medicinal supplies written or transmitted by any means of communication for purposes of validating the pharmacy record with respect to orders or refills of a legend or other prescribed drug. Documentation of an oral prescription order that has been verified by the prescribing health care provider shall meet the provisions of t
41-6604
TITLE 41 INSURANCE CHAPTER 66 FAIR PHARMACY AUDITS ACT 41-6604. Appeals process. (1) Each person or entity conducting an audit shall establish a written appeals process under which a pharmacy may appeal an unfavorable preliminary audit report or final audit report to the person or entity. The pharmacy must submit documentation or other evidence to support its appeal. (2) Following an appeal, if the person or entity finds that an unfavorable audit report is unsubstantiated, the person or entity shall dismiss the unsubstantiated portion of the audit report. (3) Any final audit report, following the final audit appeal period, with a finding of potential criminal conduct shall be referred to the prosecuting attorney having proper jurisdiction upon completion of the appeals process. History: [41-6604, added 2023, ch. 233, sec. 1, p. 722.]
41-6605
TITLE 41 INSURANCE CHAPTER 66 FAIR PHARMACY AUDITS ACT 41-6605. Extrapolation audit prohibited. (1) As used in this section, extrapolation audit means an audit of a sample of prescription drug benefit claims submitted by a pharmacy to the person or entity conducting an audit that is then used to estimate audit results for a larger batch or group of claims not reviewed by the auditor. (2) No person or entity may conduct an extrapolation audit unless otherwise required by federal law or federal plans. A person or entity conducting an audit shall not use the accounting practice of extrapolation in calculating recoupments or penalties for audits. History: [41-6605, added 2023, ch. 233, sec. 1, p. 722.]