17B:27F-7 "Clean Claim" made by a pharmacy, actions of pharmaceutical benefits managers.
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/nj/title-17b/chapter-27f/17b-27f-7·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
1. a. After the date of receipt of a clean claim for payment made by a pharmacy, a pharmacy benefits manager shall not retroactively reduce payment on the claim, either directly or indirectly, through aggregated effective rate, direct or indirect remuneration, quality assurance program, or otherwise,except if the claim is found not to be a clean claim during the course of a routine audit performed pursuant to an agreement between the pharmacy benefits manager and the pharmacy.
When a pharmacy adjudicates a claim at the point of sale, the reimbursement amount provided to the pharmacy by the pharmacy benefits manager shall constitute a final reimbursement amount. Nothing in this section shall be construed to prohibit any retroactive increase in payment to a pharmacy pursuant to a contract between the pharmacy benefits manager, and the pharmacy services administration organization, or a pharmacy.
b. For the purpose of this section, "clean claim" means a claim that has no defect or impropriety, including a lack of any required substantiating documentation, or other circumstance requiring special treatment, including, but not limited to, those listed in subsection d. of this section, that prevents timely payment from being made on the claim.
c. A pharmacy benefit manager shall not recoup funds from a pharmacy in connection with claims for which the pharmacy has already been paid unless the recoupment is:
(1)otherwise permitted or required by law;
(2)the result of an audit, performed pursuant to a contract between the pharmacy benefits manager and the pharmacy; or
(3)the result of an audit, performed pursuant to a contract between the pharmacy benefits manager and the designated pharmacy services administrative organization.
d. The provisions of this section shall not apply to an investigative audit of pharmacy records when:
(1)fraud, waste, abuse or other intentional misconduct is indicated by physical review or review of claims data or statements; or
(2)other investigative methods indicate a pharmacy is or has been engaged in criminal wrongdoing, fraud or other intentional or willful misrepresentation.
L.2019, c.274, s.1.