2013 Maryland Code
INSURANCE
§ 15-1631 - Retroactive denial or modification of reimbursement for approved claim
§15-1631.
Except for an overpayment as defined in § 15-1629(h) of this subtitle, if a claim has been approved by a pharmacy benefits manager through adjudication, the pharmacy benefits manager may not retroactively deny or modify reimbursement to a pharmacy or pharmacist for the approved claim unless:
(1) the claim was fraudulent;
(2) the pharmacy or pharmacist had been reimbursed for the claim previously;
(3) the services reimbursed were not rendered by the pharmacy or pharmacist; or
(4) subject to § 15-1629(h)(2) of this part, the claim otherwise caused monetary loss to the pharmacy benefits manager, provided that the pharmacy benefits manager allowed the pharmacy a reasonable opportunity to remedy the cause of the monetary loss.
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