This text of North Dakota § 19-03.6-02 (Pharmacy benefits manager audit - Rules) is published on Counsel Stack Legal Research, covering North Dakota primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
1.An entity conducting an audit of a pharmacy shall:
a.If conducting an onsite audit, give the pharmacy a written notice at least fourteen
business days before conducting an initial audit.
b.If the audit involves clinical or professional judgment, ensure the audit is
conducted by or in consultation with a pharmacist licensed in any state and
employed by or contracted with the pharmacy benefits manager.
c.Limit the audit to no more than twenty-four months from the date that the claim
was submitted to or adjudicated by the entity. A claim may not be reviewed that is
older than twenty-four months from the date of the audit, unless a longer period is
permitted under federal law.
d.Refrain from conducting the audit during the first five business days of the month
unless otherwise consented
Free access — add to your briefcase to read the full text and ask questions with AI
1. An entity conducting an audit of a pharmacy shall:
a. If conducting an onsite audit, give the pharmacy a written notice at least fourteen
business days before conducting an initial audit.
b. If the audit involves clinical or professional judgment, ensure the audit is
conducted by or in consultation with a pharmacist licensed in any state and
employed by or contracted with the pharmacy benefits manager.
c. Limit the audit to no more than twenty-four months from the date that the claim
was submitted to or adjudicated by the entity. A claim may not be reviewed that is
older than twenty-four months from the date of the audit, unless a longer period is
permitted under federal law.
d. Refrain from conducting the audit during the first five business days of the month
unless otherwise consented to by the pharmacy.
e. Refrain from entering the pharmacy area where patient-specific information is
available and remain out of sight and hearing range of the pharmacy customers.
The pharmacy shall designate an area for auditors to conduct their business.
f. Allow the pharmacy to use the records, including a medication administration
record, of a hospital, physician, or other authorized practitioner to validate the
pharmacy record and delivery.
g. Allow the pharmacy to use any legal prescription, including medication
administration records, electronic documents, or documented telephone calls
from the prescriber or the prescriber's agents, to validate claims in connection
with prescriptions and refills or changes in prescriptions.
2. An audit may not allow a recoupment to be assessed for items on the face of a
prescription not required by rules adopted by the state board of pharmacy with respect
to patient hard copy prescription forms for controlled and uncontrolled drugs.
3. A finding of overpayment or underpayment may be based only on the actual
overpayment or underpayment and not on 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. A calculation of an overpayment may not include dispensing fees,
unless a prescription was not dispensed or the prescriber denied authorization. In the
case of an error that has no financial harm to the patient or plan, the pharmacy
benefits manager may not assess any chargeback. The entity conducting the audit
may not use extrapolation in calculating the recoupment or penalties for audits. Any
recoupment may not be deducted against future remittances and must be invoiced to
the pharmacy for payment. An entity performing an audit may not receive payment
based on a percentage of the amount recovered. Interest may not accrue during the
audit period, which begins with the notice of audit and ends with the final audit report.
4. A clerical or recordkeeping error may not be considered fraud, but may be subject to
recoupment. A person is not subject to any criminal penalty for a clerical or
recordkeeping error without proof of intent to commit fraud.
5. The parameters of an audit must comply with consumer-oriented parameters based on
manufacturer listings or recommendations for the following:
a. The day supply for eye drops must be calculated so that the consumer pays only
one 30-day copayment if the bottle of eye drops is intended by the manufacturer
to be a thirty-day supply.
b. The day supply for insulin must be calculated so that the highest dose prescribed
is used to determine the day supply and consumer copayment.
c. The day supply for a topical product must be determined by the judgment of the
pharmacist based upon the treated area.
6. Unless an alternate price is published in a provider contract and signed by both
parties, the usual and customary price charged by a pharmacy for compounded
medications is considered to be the reimbursable cost.
7. An entity conducting an audit shall utilize the same standards and parameters in
auditing a pharmacy the entity uses with other similarly situated pharmacies.
8. An entity conducting an audit shall establish a written appeals process.