New Jersey Statutes 17B:27F-7. “Clean Claim” made by a pharmacy, actions of pharmaceutical benefits managers
Terms Used In New Jersey Statutes 17B:27F-7
- Contract: A legal written agreement that becomes binding when signed.
- Fraud: Intentional deception resulting in injury to another.
b. For the purpose of this section, “clean claim” means a claim that has no defect or impropriety, including a lack of any required substantiating documentation, or other circumstance requiring special treatment, including, but not limited to, those listed in subsection d. of this section, that prevents timely payment from being made on the claim.
c. A pharmacy benefit manager shall not recoup funds from a pharmacy in connection with claims for which the pharmacy has already been paid unless the recoupment is:
(1) otherwise permitted or required by law;
(2) the result of an audit, performed pursuant to a contract between the pharmacy benefits manager and the pharmacy; or
(3) the result of an audit, performed pursuant to a contract between the pharmacy benefits manager and the designated pharmacy services administrative organization.
d. The provisions of this section shall not apply to an investigative audit of pharmacy records when:
(1) fraud, waste, abuse or other intentional misconduct is indicated by physical review or review of claims data or statements; or
(2) other investigative methods indicate a pharmacy is or has been engaged in criminal wrongdoing, fraud or other intentional or willful misrepresentation.
L.2019, c.274, s.1.