§ 73-21-175. Short title
Sections 73-21-175 through 73-21-189 shall be known as “The Pharmacy Audit Integrity Act.”
§ 73-21-177. Purpose
The purpose of Sections 73-21-175 through 73-21-189 is to establish minimum and uniform standards and criteria for the audit of pharmacy records by or on behalf of certain entities.
§ 73-21-179. Definitions
For purposes of Sections 73-21-175 through 73-21-189: “Entity” means a pharmacy benefit manager, a managed care company, a health plan sponsor, an insurance company, a third-party payor, or any company, group or agent that represents or is engaged by those entities. “Health insurance plan” means benefits consisting of prescription drugs, other products and supplies, and […]
§ 73-21-181. Application
Sections 73-21-175 through 73-21-189 shall apply to any audit of the records of a pharmacy conducted by a managed care company, nonprofit hospital or medical service organization, insurance company, third-party payor, pharmacy benefit manager, a health program administered by a department of the state or any entity that represents those companies, groups, or department.
§ 73-21-183. Audit procedures; written report; report requirements
The entity conducting an audit shall follow these procedures: The pharmacy contract must identify and describe in detail the audit procedures; The entity conducting the on-site audit must give the pharmacy written notice at least two (2) weeks before conducting the initial on-site audit for each audit cycle, and the pharmacy shall have at least […]
§ 73-21-185. Appeals; dismissal of audit report; mediation of unresolved issues
Each entity conducting an audit shall establish a written appeals process under which a pharmacy may appeal an unfavorable preliminary audit report to the entity. If, following the appeal, the entity finds that an unfavorable audit report or any portion thereof is unsubstantiated, the entity shall dismiss the audit report or that portion without the […]
§ 73-21-187. Use of extrapolation in calculating recoupments or penalties prohibited
Notwithstanding any other provision in Sections 73-21-175 through 73-21-189, the entity conducting the audit shall not use the accounting practice of extrapolation in calculating recoupments or penalties for audits. An extrapolation audit means an audit of a sample of prescription drug benefit claims submitted by a pharmacy to the entity conducting the audit that is […]
§ 73-21-189. Limitation of applicability of Sections 73-21-175 through 73-21-189
Sections 73-21-175 through 73-21-189 do not apply to any audit, review or investigation that involves alleged fraud, willful misrepresentation or abuse.
§ 73-21-191. Penalty for noncompliance with Sections 73-21-175 through 73-21-189
The State Board of Pharmacy may impose a monetary penalty on pharmacy benefit managers for noncompliance with the provisions of the Pharmacy Audit Integrity Act, Sections 73-21-175 through 73-21-189, in amounts of not less than One Thousand Dollars ($1,000.00) per violation and not more than Twenty-five Thousand Dollars ($25,000.00) per violation.The board shall prepare a […]