PocketLaw | Georgia Code | Participating Pharmacies; Claim

Participating Pharmacies; Claim Reimbursements; Cancellation of Contracts

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A program offered in this state and not exempt under subsection (b) of Code Section 26-4-143 shall provide all of the following:
1. A statement of the method, frequency, and amount of claim reimbursement to participating pharmacies;
2. That any valid claim for pharmaceuticals under this program will be paid to a participating pharmacy within 30 days after the claim is received by the administrator if that claim is complete, accurate, and legible, as determined by the administrator;
3. That any valid claim not paid as required in paragraph (2) of this Code section shall be subject to interest at the rate specified in paragraph (1) of subsection (b) of Code Section 33-25-10, relating to payment of interest on life insurance proceeds;
4. That reimbursement rates for pharmaceuticals shall not be less than the prevailing rates therefor paid by consumers who are not enrollees;
5. That each participating pharmacy and enrollee will be notified in writing by the administrator of the cancellation of any program at least 30 days prior to the effective date of cancellation, except that where the administrator is not notified of such cancellation at least 30 days prior to the effective date of cancellation, the written notice shall be provided within 30 days after the administrator received his or her notification;
6. That program identification cards issued to an enrollee show an expiration date;
7. That the administrator shall make reasonable efforts to gain possession of all program identification cards upon cancellation of a program for which the cards were issued;
8. That a valid claim by a participating pharmacy will not be denied upon the basis of the fraudulent use of a program identification card;
9. That at least 30 days prior to the date a program becomes effective, the program contract therefor shall be offered to all pharmacies located within those counties wherein reside enrollees in that program, which pharmacies shall have at least 30 days from the time they receive the offer to accept that offer and become participating pharmacies;
10. That any audit by a program to verify claims by a participating pharmacy shall comply with generally accepted accounting principles and procedures but shall not extrapolate randomly sampled data as a basis for reimbursement from the pharmacy which is audited or from one participating pharmacy to be the corresponding data for another participating pharmacy. In the event a claim against a participating pharmacy for reimbursement is based upon a program audit, the administrator of the program shall submit details of the audit to that participating pharmacy, and any dispute relating thereto shall be resolved under the dispute resolution procedures required under paragraph (11) of this subsection, with the Commissioner to render a final binding decision in the dispute if either party is dissatisfied with the outcome under the dispute resolution procedure; and
11. A dispute resolution procedure for disputes between the program or administrator and participating pharmacies and between the program or administrator and enrollees.
A program which meets the requirements of subsection (a) of this Code section shall not be administered except in conformity with those requirements, and the administration of that program except in conformity with those requirements shall constitute a violation of this Code section by the administrator of that program.

(Code 1981, §26-4-144, enacted by Ga. L. 1998, p. 686, § 1; Ga. L. 1999, p. 81, § 26.)

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