§ 19-03.6-04 — Applicability

North Dakota § 19-03.6-04

• Jurisdiction: North Dakota
• Title 19: Foods, Drugs, Oils, and Compounds
• Ch. 19-03.6: Pharmacy Records Audits

Text

1. This chapter applies to claims adjudicated after July 31, 2011.
2. This chapter does not apply to any audit, review, or investigation that is initiated based
upon alleged fraud, willful misrepresentation, or abuse, including:
a. Insurance fraud as defined in chapter 26.1-02.1.
b. Billing for services not furnished or supplies not provided.
c. Billing that appears to be a deliberate application for duplicate payment for the
same services or supplies, billing both the beneficiary and the pharmacy benefits
manager or payer for the same service.
d. Altering claim forms, electronic claim records, or medical documentation to obtain
a higher payment amount.
e. Soliciting, offering, or receiving a kickback or bribe.

f. Participating in any scheme that involves collusion between a provider and a
beneficiary or between a supplier and a provider which results in higher costs or
charges to the entity.
g. Misrepresenting a date or description of services furnished or the identity of the
beneficiary or the individual who furnished the services.
h. Billing for a prescription without a prescription on file in a situation in which an
over-the-counter item is dispensed.
i. Dispensing a prescription using an out-of-date drug.
j. Billing with an incorrect national drug code or billing for a brand name when a
generic drug is dispensed.
k. Failing to credit the payer for a medication or a portion of a prescription that was
not obtained by the payer within fourteen days unless extenuating circumstances
exist.
l. Billing the payer a higher price than the usual and customary charge of the
pharmacy to the general public.
m. Billing for a product without proof that the purchaser purchased the product.
3. Any case of suspected fraud or violation of law must be reported by an auditor to the
licensing board.
4. This chapter does not apply to state Medicaid programs.