Pharmacy Audits. The MCO must comply with the requirements of Texas Insurance Code § 843.3401, regarding audits of pharmacists and pharmacies, including the prohibition on the use of extrapolation.
Pharmacy Audits. Administrator shall, as required by applicable Laws and Regulations and at its own expense, conduct real-time and retrospective desk audits and selected on-site audits of the Network Pharmacies to determine whether the Network Pharmacies are submitting appropriate xxxxxxxx, in compliance with Network Pharmacy Contracts, applicable Laws and Regulations and for payment by United or Members. On site audits will be conducted on no less than four percent (4%) of high volume pharmacies of the auditable base network for claims processed across the entire Administrator book of business in the prior year. For purposes of this Agreement, “high volume pharmacies” are pharmacies with at least $250,000 or greater in annual billing for the prior year. Administrator shall report the results of such audits to United. The Administrator shall provide monthly reports of all real-time and retrospective desk audit activity and recoveries in addition to a quarterly audit summary of all audit activity. The amount of all recoveries made from these activities will be paid to United or applied as a credit to invoices payable by United to Administrator. All expenses incurred in connection with audits of Network Pharmacies requested by United, not required by applicable Laws and Regulations, will be the financial responsibility of United. Any errors or overpayments detected through such an audit will be corrected and adjusted back to the proper account of United. United may request an audit of a specific Network Pharmacy, may accompany Administrator on audits, or may conduct its own audit of Network Pharmacies directly or through a third party at its own expense and upon prior notice to Administrator. Any claims requiring reprocessing due to Network Pharmacy audits conducted by a third party selected by United shall be subject to a per claim reprocessing fee as set forth on Exhibit C-1, et seq., as applicable. Network audits performed by Administrator shall be subject to the fees stated in Exhibit C-1, et seq., as applicable.
Pharmacy Audits. During the term of the Agreement, and at any time within six (6) months following its termination, a mutually agreeable entity (“Auditor”) may conduct an annual pharmacy claims audit of UMR’s performance under the Agreement once each calendar year. Prior to the commencement of this audit, UMR must receive a signed, a mutually agreeable confidentiality agreement. Customer must advise UMR in writing of its intent to audit. The place, time, type, duration, and frequency of all audits must be reasonable and agreed to by UMR. No audits may be initiated or conducted during the months of December and January due to the demands of annual renewals and the implementation period. All audits will be limited to information relating to the calendar year in which the audit is conducted, and/or the immediately preceding calendar year. The audit scope and methodology will be consistent with generally acceptable auditing standards, including a statistically valid random sample as approved by UMR. UMR will not support any external audits a) where the audit firm is paid on a contingency basis, or b) that do not use a statistically valid random selection methodology; this includes electronic/data mining audits that are used for purposes of recovery discovery. Customer will pay any expenses that it or its Auditor incurs in connection with the audit. In addition to Customer’s expenses and any applicable fees, Customer will also pay any extraordinary expenses UMR incurs due to a customer request related to the audit, such fees to be reviewed and approved by the Customer in advance. For any audit initiated after this Agreement is terminated or for any audit in addition to those provided for in this Section (if approved by UMR), Customer will pay all expenses incurred by UMR. UMR will provide Auditor with access to prescription claims data, subject to the provisions of the confidentiality agreement. Additional documentation (e.g. policies and procedures) requested during the course of an audit, other than that needed to determine the accuracy of pharmacy claims payments, may be provided at UMR’s reasonable discretion. After reviewing the claims for the audit period, Service Comments Auditor may provide a sample size of claims, not to exceed 300 prescription claims per audit, for UMR to perform additional research. A final audit report shall be provided by Customer or Auditor in writing to UMR forty-five (45) days after the end of the audit. Such final audit report will contain a re...
Pharmacy Audits. Navitus shall maintain a pharmacy audit program, the criteria of which may be amended from time to time. The audit may be conducted by Navitus' internal auditors or its outside auditors at the Participating Pharmacy or at Navitus by a review of electronically submitted Claims. Any overpayments made to a Participating Pharmacy attributable to Client's Claims will be offset against future payments to that Participating Pharmacy or Non- Participating Pharmacy from Client's account. If offset is not available, then any overpayment recovered from the Participating Pharmacy will be promptly remitted to Client. Navitus will promptly use commercially reasonable efforts to recover any overpayment from a Participating Pharmacy or Non-Participating Pharmacy. Navitus will not be required to commence any litigation to recover any such overpayments if, in Navitus’ reasonable discretion, it deems such actions not to be economically feasible. In addition, if Navitus commences litigation to recover such amounts, then all expenses incurred by Navitus with regard to such litigation may be offset against any amounts recovered.
Pharmacy Audits
