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§ 15-1630. Internal review process and determination by pharmacy benefits manager

West's Annotated Code of MarylandInsuranceEffective: January 1, 2022

West's Annotated Code of Maryland
Insurance (Refs & Annos)
Title 15. Health Insurance
Subtitle 16. Pharmacy Benefits Managers (Refs & Annos)
Part V. Contracts with Pharmacies and Pharmacists; Audits
Effective: January 1, 2022
MD Code, Insurance, § 15-1630
§ 15-1630. Internal review process and determination by pharmacy benefits manager
Application of section
(a) This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier.
Internal review process
(b) A pharmacy benefits manager shall establish a reasonable internal review process for a pharmacy to request the review of a failure to pay the contractual reimbursement amount of a submitted claim.
Review of failure to pay contractual reimbursement amount of claim
(c) A pharmacy may request a pharmacy benefits manager to review a failure to pay the contractual reimbursement amount of a claim within 180 calendar days after the date the submitted claim was paid by the pharmacy benefits manager.
Notice of review decision
(d) The pharmacy benefits manager shall give written notice of its review decision within 90 calendar days after receipt of a request for review from a pharmacy under this section.
Underpayment determinations
(e) If the pharmacy benefits manager determines through the internal review process established under subsection (b) of this section that the pharmacy benefits manager underpaid a pharmacy, the pharmacy benefits manager shall pay any money due to the pharmacy within 30 working days after completion of the internal review process.
Construction of section
(f) This section may not be construed to limit the ability of a pharmacy and a pharmacy benefits manager to contractually agree that a pharmacy may have more than 180 calendar days to request an internal review of a failure of the pharmacy benefits manager to pay the contractual amount of a submitted claim.

Credits

Added by Acts 2008, c. 262, § 1, eff. Oct. 1, 2008. Amended by Acts 2008, c. 36, § 6, eff. April 8, 2008; Acts 2021, c. 358, § 1, eff. Jan. 1, 2022.
MD Code, Insurance, § 15-1630, MD INSURANCE § 15-1630
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
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