Montana Code 33-2-2006. Onsite audits — preliminary and final reports — appeals
33-2-2006. Onsite audits — preliminary and final reports — appeals. For audits conducted onsite, the following provisions apply:
Terms Used In Montana Code 33-2-2006
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Audit: means a review of the records of a pharmacy by or on behalf of an entity that finances or reimburses the cost of health care services or pharmaceutical products. See Montana Code 33-2-2002
- Contract: A legal written agreement that becomes binding when signed.
- Entity: includes :
(a)a pharmacy benefits manager;
(b)a health benefit plan;
(c)a third-party administrator; and
(d)a company, group, or agent that represents or is engaged by one of the entities described in this subsection (2). See Montana Code 33-2-2002
- Process: means a writ or summons issued in the course of judicial proceedings. See Montana Code 1-1-202
(1)An entity that audits a pharmacy shall provide the pharmacy with a preliminary audit report, delivered to the pharmacy or its corporate office of record within 60 days after completion of the audit.
(2)A pharmacy has 30 days following receipt of the preliminary audit report to respond to questions, provide additional documentation, and comment on and clarify findings of the audit. The date of receipt of the report must be determined by the postmark date or the date of the electronic transmission if transferred electronically.
(3)If an audit results in the dispute or denial of a claim, the entity conducting the audit shall allow the pharmacy, for 30 days following receipt of the preliminary audit report, to produce additional claims documentation using any commercially reasonable method, including fax, mail, or e-mail.
(4)(a) Within 120 days after the completion of the appeals process under subsection (5), a final audit report must be delivered to the pharmacy or its corporate office of record.
(b)The final audit report must include a disclosure of any money recovered by the entity that conducted the audit.
(5)An entity that audits a pharmacy shall establish a written policy for a pharmacy to appeal a final audit report. If no remedies are specified by contract or in the pharmacy services manual, the pharmacy may seek to resolve the dispute through mediation.