RCW 48.200.210 Definitions applicable to RCW 48.200.220 through 48.200.290. The definitions in this section apply throughout this section and RCW 48.200.220 through 48.200.290 unless the context clearly requires otherwise. (1) “Audit” means an on-site or remote review of the records of a pharmacy by or on behalf of an entity. (2) “Claim” means a request […]
RCW 48.200.220 Auditing of claims—Requirements—Prohibited practices. An entity that audits claims or an independent third party that contracts with an entity to audit claims: (1) Must establish, in writing, a procedure for a pharmacy to appeal the entity’s findings with respect to a claim and must provide a pharmacy with a notice regarding the procedure, […]
RCW 48.200.230 Basis of finding of claim. An entity’s finding that a claim was incorrectly presented or paid must be based on identified transactions and not based on probability sampling, extrapolation, or other means that project an error using the number of patients served who have a similar diagnosis or the number of similar prescriptions […]
RCW 48.200.240 Contract with third party—Prohibited practices. An entity that contracts with an independent third party to conduct audits may not: (1) Agree to compensate the independent third party based on a percentage of the amount of overpayments recovered; or (2) Disclose information obtained during an audit except to the contracting entity, the pharmacy subject […]
RCW 48.200.250 Evidence of validation of claim. For purposes of RCW 48.200.210 through 48.200.270, an entity, or an independent third party that contracts with an entity to conduct audits, must allow as evidence of validation of a claim: (1) An electronic or physical copy of a valid prescription if the prescribed drug was, within fourteen […]
RCW 48.200.260 Preliminary audit report—Dispute or denial of claim—Final audit report—Recoupment of disputed funds. (1)(a) After conducting an audit, an entity must provide the pharmacy that is the subject of the audit with a preliminary report of the audit. The preliminary report must be received by the pharmacy no later than forty-five days after the […]
RCW 48.200.270 Application. RCW 48.200.210 through 48.200.270 do not: (1) Preclude an entity from instituting an action for fraud against a pharmacy; (2) Apply to an audit of pharmacy records when fraud or other intentional and willful misrepresentation is indicated by physical review, review of claims data or statements, or other investigative methods; or (3) […]
RCW 48.200.280 Predetermination of reimbursement costs—Appeals—Review by commissioner. (1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise. (a) “List” means the list of drugs for which predetermined reimbursement costs have been established, such as a maximum allowable cost or maximum allowable cost list or any other benchmark prices […]
RCW 48.200.290 Enforcement—Disputes—Civil penalties. (1) The commissioner shall have enforcement authority over this chapter and shall have authority to render a binding decision in any dispute between a pharmacy benefit manager, or third-party administrator of prescription drug benefits, and a pharmacy arising out of an appeal under RCW 48.200.280(6) regarding drug pricing and reimbursement. (2) […]
RCW 48.200.900 Rule making—2020 c 240. The insurance commissioner may adopt any rules necessary to implement this act. [ 2020 c 240 § 20.]
RCW 48.200.901 Effective date—2020 c 240. Sections 1 through 19 of this act take effect January 1, 2022. [ 2020 c 240 § 23.]
