Iowa Code 510B.8C – Clean claims
Current as of: 2023 | Check for updates
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After the date of receipt of a clean claim submitted by a pharmacy in a pharmacy network, a pharmacy benefits manager shall not retroactively reduce payment on the claim, either directly or indirectly except in the following circumstances:
1. The claim is found not to be a clean claim during the course of a routine audit.
Terms Used In Iowa Code 510B.8C
- Clean claim: means a claim that has no defect or impropriety, including a lack of any required substantiating documentation, or other circumstances requiring special treatment, that prevents timely payment from being made on the claim. See Iowa Code 510B.1
- following: when used by way of reference to a chapter or other part of a statute mean the next preceding or next following chapter or other part. See Iowa Code 4.1
- network: means pharmacies that have contracted with a pharmacy benefits manager to dispense or sell prescription drugs to covered persons of a health benefit plan for which the pharmacy benefits manager manages the prescription drug benefit. See Iowa Code 510B.1
- Pharmacy: means the same as defined in section 155A. See Iowa Code 510B.1
- Pharmacy benefits manager: means a person who, pursuant to a contract or other relationship with a third-party payor, either directly or through an intermediary, manages a prescription drug benefit provided by the third-party payor. See Iowa Code 510B.1
2. The claim submission was fraudulent.
3. The claim submission was a duplicate submission of a claim for which the pharmacy had already received payment.