Texas § IN.1369.259 - LIMITATIONS ON PAYMENT ADJUSTMENTS AND RECOUPMENT

§ IN.1369.259. LIMITATIONS ON PAYMENT ADJUSTMENTS AND RECOUPMENT

LIMITATIONS ON PAYMENT ADJUSTMENTS AND RECOUPMENT; USE OF EXTRAPOLATION PROHIBITED. (a) A health benefit plan issuer or pharmacy benefit manager may not calculate the amount of a recoupment based on: (1) an absence of documentation the pharmacist or pharmacy is not required by applicable federal laws and regulations and state laws and rules to maintain; or (2) an error that does not result in actual financial harm to the patient or enrollee, the health benefit plan issuer, or the pharmacy benefit manager. (a-1) Subject to Subsections (e) and (f), a health benefit plan issuer or pharmacy benefit manager may not, as the result of an audit, deny or reduce a claim payment made to a pharmacist or pharmacy after adjudication of the claim. (b) A health benefit plan issuer or pharmacy benefit manager may not require extrapolation audits as a condition of participation in a contract, network, or program for a pharmacist or pharmacy. (c) A health benefit plan issuer or pharmacy benefit manager may not use extrapolation to complete an on-site audit or a desk audit of a pharmacist or pharmacy. Notwithstanding Subsection (a)(2), the amount of a recoupment must be based on the actual overpayment or underpayment and may not be based on an extrapolation. (d) Repealed by Acts 2025, 89th Leg., R.S., Ch. 183 (S.B. 1236 ), Sec. 6, eff. September 1, 2025. (e) A health benefit plan issuer or pharmacy benefit manager may recoup from a pharmacist or pharmacy the cost of a prescription drug and the dispensing fee for the drug if: (1) the original claim was submitted fraudulently; (2) the original claim payment was incorrect because the pharmacist or pharmacy had already been paid for the pharmacist service; or (3) the pharmacist or pharmacy made a substantive nonclerical or non-recordkeeping error that led to the patient receiving the wrong prescription drug or dosage. (f) A health benefit plan issuer or pharmacy benefit manager may recoup only the dispensing fee from a pharmacist or pharmacy if the pharmacist or pharmacy made a clerical error that led to an overpayment. Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358 ), Sec. 1, eff. September 1, 2013. Amended by: Acts 2025, 89th Leg., R.S., Ch. 183 (S.B. 1236 ), Sec. 2, eff. September 1, 2025. Acts 2025, 89th Leg., R.S., Ch. 183 (S.B. 1236 ), Sec. 3, eff. September 1, 2025. Acts 2025, 89th Leg., R.S., Ch. 183 (S.B. 1236 ), Sec. 6, eff. September 1, 2025.