58-29F-6. Recoupment or chargeback criteria.
For recoupment or chargeback, the following criteria apply:
(1)Audit parameters shall consider consumer-oriented parameters based on manufacturer listings;
(2)A pharmacy's usual and customary price for compounded medications is considered the reimbursable cost unless the pricing methodology is outlined in the provider contract;
(3)A finding of overpayment or underpayment can only be based on the actual overpayment or underpayment and not a projection based on the number of patients served having a similar diagnosis or on the number of similar orders or refills for similar drugs;
(4)The entity conducting the audit may not use extrapolation in calculating the recoupment or penalties for audits unless required by state or federal law or regulation;
(5)Calculations of overpayments may not include dispensing fees unless:
(a)A prescription was not actually dispensed;
(b)The prescriber denied authorization;
(c)The prescription dispensed was a medication error by the pharmacy; or
(d)The identified overpayment is solely based on an extra dispensing fee;
(6)An entity may not consider any clerical or record-keeping error, such as a typographical error, scrivener's error, or computer error regarding a required document or record as fraud. However, such errors may be subject to recoupment;
(7)In the case of errors that have no actual financial harm to the patient or plan, the pharmacy benefits manager may not assess any chargebacks. Errors that are a result of the pharmacy's failing to comply with a formal corrective action plan may be subject to recovery; and
(8)Interest may not accrue during the audit period for either party. The audit period begins with the notice of the audit and ends with the final audit report.
Source: SL 2013, ch 254, §6.