§ 3801. Definitions As used in this subchapter: (1)(A) “Health insurer” shall have the same meaning as in section 9402 of this title and shall include: (i) a health insurance company, a nonprofit hospital and medical service corporation, and health maintenance organizations; (ii) an employer, a labor union, or another group of persons organized in […]
§ 3802. Pharmacy rights during an audit Notwithstanding any provision of law to the contrary, whenever a health insurer, a third-party payer, or an entity representing a responsible party conducts an audit of the records of a pharmacy, the pharmacy shall have a right to all of the following: (1) To have an audit involving […]
§ 3803. Appeals (a) An entity that audits a pharmacy shall provide the pharmacy with a preliminary audit report, which shall be delivered to the pharmacy or to its corporate office of record within 60 days following completion of the audit. (b) A pharmacy shall have 30 days following receipt of the preliminary audit report […]
§ 3804. Pharmacy audit recoupments (a) Recoupment of any disputed funds shall occur only after the final internal disposition of an audit, including the appeals process set forth in section 3803 of this title. (b) An entity conducting an audit may not: (1) include dispensing fees in calculations of overpayments unless the prescription is determined […]
§ 3805. Applicability The provisions of this chapter shall not apply to any audit or investigation undertaken by any State agency, including the Office of the Attorney General or the Agency of Human Services, to a fiscal agent of the State, or to any audit, review, or investigation that involves alleged Medicaid fraud, Medicaid waste, […]
