Sec. 21.27.930. Pharmacy audit appeal; future repayment.
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Sec. 21.27.930. Pharmacy audit appeal; future repayment.
(a)A pharmacy benefits manager conducting an audit shall establish a written appeals process.
(b)Recoupment of disputed funds or repayment of funds to the pharmacy benefits manager by the pharmacy, if permitted by contract, shall occur, to the extent demonstrated or documented in the pharmacy audit findings, after final internal disposition of the audit, including the appeals process. If the identified discrepancy for an individual audit exceeds $15,000, future payments to the pharmacy may be withheld pending finalization of the audit.
(c)A pharmacy benefits manager may not assess against a pharmacy a charge- back, recoupment, or other penalty until the pharmacy benefits manager's appeals process has been exhausted and the final report or settlement agreement issued.