If an overpayment determination is the result of retroactive review or audit of coverage decisions or payment levels not related to fraud, a health maintenance organization shall adhere to the following procedures:
1. All claims for overpayment must be submitted to a provider within 30 months after the health maintenance organization's payment of the claim. A provider must pay, deny, or contest the health maintenance organization's claim for overpayment within 40 days after the receipt of the claim. All contested claims for overpayment must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny overpayment and claim within 140 days after receipt creates an uncontestable obligation to pay the claim.
2. A provider that denies or contests a health maintenance organization's claim for overpayment or any portion of a claim shall notify the organization, in writing, within 35 days after the provider receives the claim that the claim for overpayment is contested or denied. The notice that the claim for overpayment is denied or contested must identify the contested portion of the claim and the specific reason for contesting or denying the claim and, if contested, must include a request for additional information. If the organization submits additional information, the organization must, within 35 days after receipt of the request, mail or electronically transfer the information to the provider. The provider shall pay or deny the claim for overpayment within 45 days after receipt of the information. The notice is considered made on the date the notice is mailed or electronically transferred by the provider.
3. The health maintenance organization may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health maintenance organization's overpayment claim as required by this paragraph.
Here are the details: A certain PBM conducted an audit of our pharmacy. They sent me the initial audit findings and said I only had 30 days to respond. I responded within 30 days, and then they sent me a final audit notice stating they would recoup the money via future payments. They audit was closed. Now, from what i can gather from the statute above, this PBM has broken the law. From how i interpret this, I should have been given 40 days from the initial findings to submit my validations. Then, when the final findings arrive, i have 35 days to notify the PBM that i am disputing their findings and i must request additional information on the claims being recouped. The PBM then must respond within 35 days to my request. After i receive their additional info, I have 45 days to pay the PBM or deny their findings. Am i understanding this correctly?
1. All claims for overpayment must be submitted to a provider within 30 months after the health maintenance organization's payment of the claim. A provider must pay, deny, or contest the health maintenance organization's claim for overpayment within 40 days after the receipt of the claim. All contested claims for overpayment must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny overpayment and claim within 140 days after receipt creates an uncontestable obligation to pay the claim.
2. A provider that denies or contests a health maintenance organization's claim for overpayment or any portion of a claim shall notify the organization, in writing, within 35 days after the provider receives the claim that the claim for overpayment is contested or denied. The notice that the claim for overpayment is denied or contested must identify the contested portion of the claim and the specific reason for contesting or denying the claim and, if contested, must include a request for additional information. If the organization submits additional information, the organization must, within 35 days after receipt of the request, mail or electronically transfer the information to the provider. The provider shall pay or deny the claim for overpayment within 45 days after receipt of the information. The notice is considered made on the date the notice is mailed or electronically transferred by the provider.
3. The health maintenance organization may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health maintenance organization's overpayment claim as required by this paragraph.
Here are the details: A certain PBM conducted an audit of our pharmacy. They sent me the initial audit findings and said I only had 30 days to respond. I responded within 30 days, and then they sent me a final audit notice stating they would recoup the money via future payments. They audit was closed. Now, from what i can gather from the statute above, this PBM has broken the law. From how i interpret this, I should have been given 40 days from the initial findings to submit my validations. Then, when the final findings arrive, i have 35 days to notify the PBM that i am disputing their findings and i must request additional information on the claims being recouped. The PBM then must respond within 35 days to my request. After i receive their additional info, I have 45 days to pay the PBM or deny their findings. Am i understanding this correctly?
