Tex.
Ins. Code Section 1369.251
Definitions
(1)
“Desk audit” means an audit conducted by a health benefit plan issuer or pharmacy benefit manager at a location other than the location of the pharmacist or pharmacy. The term includes an audit performed at the offices of the plan issuer or pharmacy benefit manager during which the pharmacist or pharmacy provides requested documents for review by hard copy or by microfiche, disk, or other electronic media. The term does not include a review conducted not later than the third business day after the date a claim is adjudicated provided recoupment is not demanded.(2)
“Extrapolation” means a mathematical process or technique used by a health benefit plan issuer or pharmacy benefit manager that administers pharmacy claims for a health benefit plan issuer in the audit of a pharmacy or pharmacist to estimate audit results or findings for a larger batch or group of claims not reviewed by the plan issuer or pharmacy benefit manager.(3)
“Health benefit plan” means a plan that provides benefits for medical, surgical, or other treatment expenses incurred as a result of a health condition, a mental health condition, an accident, sickness, or substance abuse, including:(A)
an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is issued by:(i)
an insurance company;(ii)
a group hospital service corporation operating under Chapter 842 (Group Hospital Service Corporations);(iii)
a health maintenance organization operating under Chapter 843 (Health Maintenance Organizations);(iv)
an approved nonprofit health corporation that holds a certificate of authority under Chapter 844 (Certification of Certain Nonprofit Health Corporations);(v)
a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846 (Multiple Employer Welfare Arrangements);(vi)
a stipulated premium company operating under Chapter 884 (Stipulated Premium Insurance Companies);(vii)
a fraternal benefit society operating under Chapter 885 (Fraternal Benefit Societies);(viii)
a Lloyd’s plan operating under Chapter 941 (Lloyd’s Plan); or(ix)
an exchange operating under Chapter 942 (Reciprocal and Interinsurance Exchanges);(B)
a small employer health benefit plan written under Chapter 1501 (Health Insurance Portability and Availability Act); or(C)
a health benefit plan issued under Chapter 1551 (Texas Employees Group Benefits Act), 1575 (Texas Public School Employees Group Benefits Program), 1579 (Texas School Employees Uniform Group Health Coverage), or 1601 (Uniform Insurance Benefits Act for Employees of the University of Texas System and the Texas A&m University System).(4)
“On-site audit” means an audit that is conducted at:(A)
the location of the pharmacist or pharmacy; or(B)
another location at which the records under review are stored.(5)
“Pharmacy benefit manager” has the meaning assigned by Section 4151.151 (Definition).
Source:
Section 1369.251 — Definitions, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1369.htm#1369.251 (accessed Jun. 5, 2024).
