Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT HEADING: PL 1997, C. 792, §2 (RPR)
Subchapter 1: HEALTH PLAN REQUIREMENTS HEADING: PL 1997, C. 792, §2 (NEW)
§4317. Pharmacy providers
1.Contracts with pharmacy providers.
Notwithstanding section 2672, section 4307, subsection 3 and Title 32, chapter 117, subchapter 8, a carrier that provides
coverage for prescription drugs as part of a health plan may not refuse to contract with a pharmacy provider that is qualified
and is willing to meet the terms and conditions of the carrier's criteria for pharmacy participation as stipulated in the
carrier's contractual agreement with its pharmacy providers.
This subsection may not be construed to limit a carrier's ability to offer an enrollee incentives, including variations in
premiums, deductibles, copayments or coinsurance or variations in the quantities of medications available to the enrollee,
to encourage the use of certain preferred pharmacy providers as long as the carrier makes the terms applicable to the preferred
pharmacy providers available to all pharmacy providers. For purposes of this subsection, a preferred pharmacy provider is
any pharmacy willing to meet the specified terms, conditions and price that the carrier may require for its preferred pharmacy
providers.
[
2009, c. 519, §1 (NEW);
2009, c. 519, §2 (AFF)
.]
2.Prompt payment of claims.
Notwithstanding section 2436, the following provisions apply to the payment of claims submitted to a carrier by a pharmacy
provider.
A. For purposes of this subsection, the following terms have the following meanings.
(1) "Applicable number of calendar days" means:
(a) With respect to claims submitted electronically, 21 days; and
(b) With respect to claims submitted otherwise, 30 days.
(2) "Clean claim" means a claim that has no defect or impropriety, including any lack of any required substantiating documentation,
or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this
section. [2009, c. 519, §1 (NEW); 2009, c. 519, §2 (AFF).]
B. A contract entered into by a carrier with a pharmacy provider with respect to a prescription drug plan offered by a carrier
must provide that payment is issued, mailed or otherwise transmitted with respect to all clean claims submitted by a pharmacy
provider, other than a pharmacy that dispenses drugs by mail order only or a pharmacy located in, or under contract with,
a long-term care facility, within the applicable number of calendar days after the date on which the claim is received. For
purposes of this subsection, a claim is considered to have been received:
(1) With respect to claims submitted electronically, on the date on which the claim is transferred; and
(2) With respect to claims submitted otherwise, on the 5th day after the postmark date of the claim or the date specified
in the time stamp of the transmission of the claim. [2009, c. 519, §1 (NEW); 2009, c. 519, §2 (AFF).]
C. If payment is not issued, mailed or otherwise transmitted by the carrier within the applicable number of calendar days after
a clean claim is received, the carrier shall pay interest to the pharmacy provider at the rate of 18% per annum. [2009, c. 519, §1 (NEW); 2009, c. 519, §2 (AFF).]
D. A claim is considered to be a clean claim if the carrier involved does not provide notice to the pharmacy provider of any
deficiency in the claim within 10 days after the date on which an electronically submitted claim is received or within 15
days after the date on which a claim submitted otherwise is received. [2009, c. 519, §1 (NEW); 2009, c. 519, §2 (AFF).]
E. If a carrier determines that a submitted claim is not a clean claim, the carrier shall immediately notify the pharmacy provider
of the determination. The notice must specify all defects or improprieties in the claim and list all additional information
or documents necessary for the proper processing and payment of the claim. If a pharmacy provider receives notice from a carrier
that a claim has been determined to not be a clean claim, the pharmacy provider shall take steps to correct that claim and
then resubmit the claim to the carrier for payment. [2009, c. 519, §1 (NEW); 2009, c. 519, §2 (AFF).]
F. A claim resubmitted to a carrier with additional information pursuant to paragraph E is considered to be a clean claim if
the carrier does not provide notice to the pharmacy provider of any defect or impropriety in the claim within 10 days of the
date on which additional information is received if the claim is resubmitted electronically or within 15 days of the date
on which additional information is received if the claim is resubmitted otherwise. [2009, c. 519, §1 (NEW); 2009, c. 519, §2 (AFF).]
G. A claim submitted to a carrier that is not paid by the carrier or contested by the plan sponsor within the applicable number
of calendar days after the date on which the claim is received by the carrier is considered to be a clean claim and must be
paid by the carrier. [2009, c. 519, §1 (NEW); 2009, c. 519, §2 (AFF).]
H. Payment of a clean claim under this subsection is considered to have been made on the date on which the payment is transferred
with respect to claims paid electronically and on the date on which the payment is submitted to the United States Postal Service
or common carrier for delivery with respect to claims paid otherwise. [2009, c. 519, §1 (NEW); 2009, c. 519, §2 (AFF).]
I. A carrier shall pay all clean claims submitted electronically by electronic transfer of funds if the pharmacy provider so
requests or has so requested previously. In the case when the payment is made electronically, remittance may be made by the
carrier electronically. [2009, c. 519, §1 (NEW); 2009, c. 519, §2 (AFF).]
[
2009, c. 519, §1 (NEW);
2009, c. 519, §2 (AFF)
.]
3.Exception.
Subsections 1 and 2 do not apply to any medical assistance or public health programs administered by the Department of Health and Human Services,
including, but not limited to, the Medicaid program and the elderly low-cost drug program under Title 22, section 254-D.
[
2011, c. 443, §5 (AMD)
.]
4.Participation in contracts
. A pharmacy benefits manager may not require a pharmacist or pharmacy to participate in one network in order to participate
in another network. The pharmacy benefits manager may not exclude an otherwise qualified pharmacist or pharmacy from participation
in one network solely because the pharmacist or pharmacy declined to participate in another network managed by the pharmacy
benefits manager.
[
2011, c. 443, §6 (NEW)
.]
5.Prohibition.
The written contract between a carrier and a pharmacy benefits manager may not provide that the pharmacist or pharmacy is
responsible for the actions of the insurer or a pharmacy benefits manager.
[
2011, c. 443, §6 (NEW)
.]
6.Pharmacy benefits manager duties.
All contracts must provide that, when the pharmacy benefits manager receives payment for the services of a pharmacist or
pharmacy, the pharmacy benefits manager shall distribute the funds in accordance with the time frames provided in this subchapter.
[
2011, c. 691, Pt. A, §23 (AMD)
.]
7.Complaints, grievances and appeals.
A pharmacy benefits manager may not terminate the contract of or penalize a pharmacist or pharmacy solely as a result of
the pharmacist's or pharmacy's filing of a complaint, grievance or appeal. This subsection is not intended to restrict the
pharmacy's and pharmacy benefits manager's ability to enter into agreements that allow for mutual termination without cause.
[
2011, c. 443, §6 (NEW)
.]
8.Denial or limitation of benefits.
A pharmacy's benefits manager may not terminate the contract of or penalize a pharmacist or pharmacy for expressing disagreement
with a carrier's decision to deny or limit benefits to an enrollee or because the pharmacist or pharmacy assists the enrollee
to seek reconsideration of the carrier's decision or because the pharmacist or pharmacy discusses alternative medications.
[
2011, c. 443, §6 (NEW)
.]
9.Written notice required.
At least 60 days before a pharmacy's benefits manager terminates a pharmacy's or pharmacist's participation in the pharmacy
benefits manager's plan or network, the pharmacy benefits manager shall give the pharmacy or pharmacist a written explanation
of the reason for the termination, unless the termination is based on:
A. The loss of the pharmacy's license or the pharmacist's license to practice pharmacy or cancellation of professional liability
insurance; or [2011, c. 443, §6 (NEW).]
B. A finding of fraud. [2011, c. 443, §6 (NEW).]
At least 60 days before a pharmacy or pharmacist terminates its participation in a pharmacy benefits manager's plan or network,
the pharmacy or pharmacist shall give the pharmacy benefits manager a written explanation of the reason for the termination.
[
2011, c. 443, §6 (NEW)
.]
10.Audits.
Notwithstanding any other provision of law, when an on-site audit of the records of a pharmacy is conducted by a pharmacy
benefits manager, the audit must be conducted in accordance with the following criteria.
A. A finding of overpayment or underpayment must 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,
unless the projected overpayment or denial is a part of a settlement agreed to by the pharmacy or pharmacist. [2011, c. 443, §6 (NEW).]
B. The auditor may not use extrapolation in calculating recoupments or penalties. [2011, c. 443, §6 (NEW).]
C. Any audit that involves clinical or professional judgment must be conducted by or in consultation with a pharmacist. [2011, c. 443, §6 (NEW).]
D. Each entity conducting an audit shall establish an appeals process under which a pharmacy may appeal an unfavorable preliminary
audit report to the entity. [2011, c. 443, §6 (NEW).]
E. This subsection does not apply to any audit, review or investigation that is initiated based on or involves suspected or alleged
fraud, willful misrepresentation or abuse. [2011, c. 443, §6 (NEW).]
[
2011, c. 443, §6 (NEW)
.]
11.Audit information and reports.
A preliminary audit report must be delivered to the pharmacy within 60 days after the conclusion of the audit under subsection
10. A pharmacy must be allowed at least 30 days following receipt of the preliminary audit to provide documentation to address
any discrepancy found in the audit. A final audit report must be delivered to the pharmacy within 90 days after receipt of
the preliminary audit report or final appeal, whichever is later. A charge-back, recoupment or other penalty may not be assessed
until the appeal process provided by the pharmacy benefits manager has been exhausted and the final report issued. Except
as provided by state or federal law, audit information may not be shared. Auditors may have access only to previous audit
reports on a particular pharmacy conducted by that same entity.
§4317. Prohibition against maximum aggregate benefit provisions
(As enacted by PL 2009, c. 588, §1 and affected by §3 is REALLOCATED TO TITLE 24-A, SECTION 4318)
[
2011, c. 443, §6 (NEW)
.]
SECTION HISTORY
RR 2009, c. 2, §70 (RAL).
2009, c. 519, §1 (NEW).
2009, c. 519, §2 (AFF).
2009, c. 588, §1 (NEW).
2009, c. 588, §3 (AFF).
2011, c. 443, §§5, 6 (AMD).
2011, c. 691, Pt. A, §23 (AMD).
Data for this page extracted on 10/16/2012 08:29:52.