Search OpenLegislation Statutes

This entry was published on 2018-04-20
The selection dates indicate all change milestones for the entire volume, not just the location being viewed. Specifying a milestone date will retrieve the most recent version of the location before that date.
Pharmacy audits by pharmacy benefit managers
Public Health (PBH) CHAPTER 45, ARTICLE 2-A, TITLE 2
§ 280-c. Pharmacy audits by pharmacy benefit managers. 1. Definitions.
As used in this section, the following terms shall have the following

(a) "Pharmacy benefit manager" shall have the same meaning as in
section two hundred eighty-a of this article.

(b) "Pharmacy" shall mean a pharmacy that has contracted with a
pharmacy benefit manager for the provision of pharmacy services.

2. When conducting an audit of a pharmacy's records, a pharmacy
benefit manager shall:

(a) not conduct an on-site audit of a pharmacy at any time during the
first three calendar days of a month;

(b) notify the pharmacy or its contracting agent no later than fifteen
days before the date of initial on-site audit. Such notification to the
pharmacy or its contracting agent shall be in writing delivered either
(i) by mail or common carrier, return receipt requested, or (ii)
electronically with electronic receipt confirmation, addressed to the
supervising pharmacist of record and pharmacy corporate office where
applicable, at least fifteen days before the date of an initial on-site

(c) limit the audit period to twenty-four months after the date a
claim is submitted to or adjudicated by the pharmacy benefit manager;

(d) include in the written advance notice of an on-site audit the list
of specific prescription numbers to be included in the audit that may or
may not include the final two digits of the prescription numbers;

(e) use the written and verifiable records of a hospital, physician or
other authorized practitioner, which are transmitted by any means of
communication, to validate the pharmacy records in accordance with state
and federal law;

(f) limit the number of prescriptions audited to no more than one
hundred randomly selected in a twelve-month period, except in cases of

(g) provide the pharmacy or its contracting agent with a copy of the
preliminary audit report within forty-five days after the conclusion of
the audit;

(h) be allowed to conduct a follow-up audit on-site if a remote or
desk audit reveals the necessity for a review of additional claims;

(i) in the case of invoice audits, accept as validation invoices from
any wholesaler registered with the department of education from which
the pharmacy has purchased prescription drugs or, in the case of durable
medical equipment or sickroom supplies, invoices from an authorized
distributor other than a wholesaler;

(j) provide the pharmacy or its contracting agent with the ability to
provide documentation to address a discrepancy or audit finding,
provided that such documentation must be received by the pharmacy
benefit manager no later than the forty-fifth day after the preliminary
audit report was provided to the pharmacy or its contracting agent. The
pharmacy benefit manager shall consider a reasonable request from the
pharmacy for an extension of time to submit documentation to address or
correct any findings in the report; and

(k) provide the pharmacy or its contracting agent with the final audit
report no later than sixty days after the initial audit report was
provided to the pharmacy or its contracting agent.

3. Any claim that was retroactively denied for a clerical error,
typographical error, scrivener's error or computer error shall be paid
if the prescription was properly and correctly dispensed, unless a
pattern of such errors exists, fraudulent billing is alleged or the
error results in actual financial loss to the entity. A clerical error
is an error that does not result in actual financial harm to the covered
entity or consumer and does not include the dispensing of an incorrect
dose, amount or type of medication or dispensing a prescription drug to
the wrong person.

4. This section shall not apply to:

(a) audits in which suspected fraudulent activity or other intentional
or willful misrepresentation is evidenced by a physical review, review
of claims data or statements, or other investigative methods; or

(b) audits of claims paid for by federally funded programs; or

(c) concurrent reviews or desk audits that occur within three business
days of transmission of a claim and where no chargeback or recoupment is