North Dakota Code 19-03.6-04 – Applicability
1. This chapter applies to claims adjudicated after July 31, 2011.
Terms Used In North Dakota Code 19-03.6-04
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Fraud: Intentional deception resulting in injury to another.
- Individual: means a human being. See North Dakota Code 1-01-49
- State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See North Dakota Code 1-01-49
2. This chapter does not apply to any audit, review, or investigation that is initiated based upon alleged fraud, willful misrepresentation, or abuse, including:
a. Insurance fraud as defined in chapter 26.1-02.1.
b. Billing for services not furnished or supplies not provided.
c. Billing that appears to be a deliberate application for duplicate payment for the same services or supplies, billing both the beneficiary and the pharmacy benefits manager or payer for the same service.
d. Altering claim forms, electronic claim records, or medical documentation to obtain a higher payment amount.
e. Soliciting, offering, or receiving a kickback or bribe.
f. Participating in any scheme that involves collusion between a provider and a beneficiary or between a supplier and a provider which results in higher costs or charges to the entity.
g. Misrepresenting a date or description of services furnished or the identity of the beneficiary or the individual who furnished the services.
h. Billing for a prescription without a prescription on file in a situation in which an over-the-counter item is dispensed.
i. Dispensing a prescription using an out-of-date drug.
j. Billing with an incorrect national drug code or billing for a brand name when a generic drug is dispensed.
k. Failing to credit the payer for a medication or a portion of a prescription that was not obtained by the payer within fourteen days unless extenuating circumstances exist.
l. Billing the payer a higher price than the usual and customary charge of the pharmacy to the general public.
m. Billing for a product without proof that the purchaser purchased the product.
3. Any case of suspected fraud or violation of law must be reported by an auditor to the licensing board.
4. This chapter does not apply to state Medicaid programs.