Claims Fraud. Pharmacy Benefit Manager will continually monitor Claims during processing for the purpose of identifying instances of claim fraud from any source. Pharmacy Benefit Manager will use its best efforts to prevent and identify claim fraud through system design, monitoring, and any other method commonly utilized in the Pharmacy Benefit Management industry. Pharmacy Benefit Manager will bear full responsibility for curing any instance of confirmed claim fraud, including recoupment, reversing, offsetting or denying Claims, on behalf of the affected Employee Plan of payments made by that Employee Plan not arising out of the failure of the State to fulfill its obligations in this Agreement, if Pharmacy Benefit Manager recovers the amount of the Claim, which Pharmacy Benefit Manager will pursue using commercially reasonable efforts including denying payment, offsetting or reversing or recoupment of Claims, or if the Pharmacy Benefit Manager should have reasonably known that the Claim was fraudulent prior to the payment of the Claim based on industry standards in place at the time such fraud occurred. Additionally, Pharmacy Benefit Manager will use commercially reasonable efforts to assist in the recovery of amounts paid in error and coordinate with Participating Pharmacies to correct errors identified after Claims are submitted. Pharmacy Benefit Manager will notify State’s designated representative, in writing, within five (5) business day of its discovery of eligibility or confirmed claim fraud by or on behalf of an individual seeking benefits under the Employee Plan. Pharmacy Benefit Manager will provide State a written report of identified claim fraud each year, including special investigations unit cases.
