Tex.
Ins. Code Section 1369.2581
Audit Discrepancies; Wholesale Invoices
(a)
A health benefit plan issuer or pharmacy benefit manager that audits wholesale invoices during an audit of a pharmacist or pharmacy may not audit the pharmacy claims of another health benefit plan or pharmacy benefit manager.(b)
A health benefit plan issuer or pharmacy benefit manager shall reverse a finding of a discrepancy if:(1)
the National Drug Code for the dispensed drug is in a quantity that is a subunit or multiple of the drug purchased by the pharmacist or pharmacy as supported by a wholesale invoice;(2)
the pharmacist or pharmacy dispensed the correct quantity of the drug according to the prescription; and(3)
the drug dispensed by the pharmacist or pharmacy shares all but the last two digits of the National Drug Code of the drug reflected on the supplier invoice.(c)
A health benefit plan issuer or pharmacy benefit manager must accept as evidence to support the validity of a pharmacy claim related to a dispensed drug:(1)
subject to validation, including validation by pharmacy purchase order and payment of a supplier invoice, copies of supplier invoices in the pharmacist’s or pharmacy’s possession, including:(A)
supplier invoices issued before the date the drug was dispensed and not earlier than 60 days before the first day of the audit period; and(B)
invoices and any supporting documents from any supplier authorized by federal or state law to transfer ownership of the drug acquired by the pharmacist or pharmacy; and(2)
reports required by any state board or agency.(d)
A health benefit plan issuer or pharmacy benefit manager must provide, not later than the fifth business day after the date of a request by the pharmacist or pharmacy, any supporting documents the pharmacist’s or pharmacy’s suppliers provided to the health benefit plan issuer or pharmacy benefit manager.
Source:
Section 1369.2581 — Audit Discrepancies; Wholesale Invoices, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1369.htm#1369.2581 (accessed Jun. 5, 2024).
