2015 Delaware Code
Title 18 - Insurance Code
CHAPTER 33A. PHARMACY AUDIT INTEGRITY PROGRAM [EFFECTIVE SEPT. 28, 2015]
§ 3306A Documentation.
(a) To validate the pharmacy record and delivery, the pharmacy may use authentic and verifiable statements or records including medication administration records of a nursing home, assisted living facility, hospital, physician, or other authorized practitioner or additional audit documentation parameters located in the provider manual.
(b) Any legal prescription that meets the requirements in this chapter may be used to validate claims in connection with prescriptions, refills, or changes in prescriptions, including medication administration records, faxes, e-prescriptions, or documented telephone calls from the prescriber or the prescriber's agents.
80 Del. Laws, c. 65, § 1.;
§ 3307A Appeals process.
The entity conducting the audit must establish a written appeals process which must include appeals of preliminary reports and final reports.
80 Del. Laws, c. 65, § 1.;
§ 3308A Audit information and reports.
(a) A preliminary audit report must be delivered to the pharmacy within 30 days after the conclusion of the audit. The preliminary audit report shall contain claim level information for any discrepancy and an estimated recovery amount.
(b) A pharmacy must be allowed at least 45 days following receipt of the preliminary audit to provide documentation to address any discrepancy found in the audit.
(c) A final audit report must be delivered to the pharmacy within 120 days after receipt of the preliminary audit report or final appeal, whichever is later.
(d) An entity shall remit any money due to a pharmacy or pharmacist as a result of an underpayment of a claim within 45 days after the appeals process has been exhausted and the final audit report has been issued.
80 Del. Laws, c. 65, § 1.;
§ 3309A Disclosures to plan sponsor.
Where contractually required, an auditing entity must provide a copy to the plan sponsor of its claims that were included in the audit, and any recouped money shall be returned to the plan sponsor.
80 Del. Laws, c. 65, § 1.;
§ 3310A Applicability of other laws and regulations.
This chapter does not apply to any investigative audit that involves suspected fraud, wilful misrepresentation, abuse, or any audit completed by the State.
80 Del. Laws, c. 65, § 1.;
