(a) On and after January 1, 2026, a contract or a pharmacy provider manual between a pharmacy benefits manager and a pharmacy or a pharmacist shall be updated to indicate that the pharmacy benefits manager will issue, mail, or otherwise transmit payment with respect to a clean claim submitted by a pharmacy or a pharmacist:(1) Seven (7) to fourteen (14) days after the date of the receipt of a claim for an electronic claim; or(2) Thirty (30) days after the date of the receipt of a claim for any other paper or manually submitted claim.
(1) Seven (7) to fourteen (14) days after the date of the receipt of a claim for an electronic claim; or
(2) Thirty (30) days after the date of the receipt of a claim for any other paper or manually submitted claim.
(b) (1) A claim is a clean claim if the pharmacy benefits manager receiving the claim does not provide notice to the submitting pharmacist or pharmacy of any deficiency or error in the claim within:(A) Ten (10) days after the date of the receipt of a claim for an electronic claim; or(B) Fifteen (15) days after the date of the receipt of a claim for any other manual or paper claim.(2) (A) If a pharmacy benefits manager determines that a submitted claim is not a clean claim, the pharmacy benefits manager shall notify the submitting pharmacy or pharmacist of the determination within the period described under subdivision (b)(1) of this section.(B) The notification required under subdivision (b)(2)(A) of this section shall:(i) Be submitted in writing or electronically by email to the pharmacist or pharmacy to specify all defects, clerical errors, or improprieties in the claim; and(ii) List any additional information necessary for the proper processing and payment of the claim.(3) (A) After the additional information described in subdivision (b)(2)(B)(ii) of this section is submitted by the network pharmacy, a claim becomes a clean claim within ten (10) days if the pharmacy benefits manager does not provide notice to the submitting network pharmacy of any remaining defect or impropriety in the claim or of any new defect or impropriety in the additional information submitted.(B) A pharmacy benefits manager shall not provide notice of a new deficiency or impropriety in the claim that could have been identified by the pharmacy benefits manager in the original claim submission under this subsection.
(1) A claim is a clean claim if the pharmacy benefits manager receiving the claim does not provide notice to the submitting pharmacist or pharmacy of any deficiency or error in the claim within:(A) Ten (10) days after the date of the receipt of a claim for an electronic claim; or(B) Fifteen (15) days after the date of the receipt of a claim for any other manual or paper claim.
(A) Ten (10) days after the date of the receipt of a claim for an electronic claim; or
(B) Fifteen (15) days after the date of the receipt of a claim for any other manual or paper claim.
(2) (A) If a pharmacy benefits manager determines that a submitted claim is not a clean claim, the pharmacy benefits manager shall notify the submitting pharmacy or pharmacist of the determination within the period described under subdivision (b)(1) of this section.(B) The notification required under subdivision (b)(2)(A) of this section shall:(i) Be submitted in writing or electronically by email to the pharmacist or pharmacy to specify all defects, clerical errors, or improprieties in the claim; and(ii) List any additional information necessary for the proper processing and payment of the claim.
(A) If a pharmacy benefits manager determines that a submitted claim is not a clean claim, the pharmacy benefits manager shall notify the submitting pharmacy or pharmacist of the determination within the period described under subdivision (b)(1) of this section.
(B) The notification required under subdivision (b)(2)(A) of this section shall:(i) Be submitted in writing or electronically by email to the pharmacist or pharmacy to specify all defects, clerical errors, or improprieties in the claim; and(ii) List any additional information necessary for the proper processing and payment of the claim.
(i) Be submitted in writing or electronically by email to the pharmacist or pharmacy to specify all defects, clerical errors, or improprieties in the claim; and
(ii) List any additional information necessary for the proper processing and payment of the claim.
(3) (A) After the additional information described in subdivision (b)(2)(B)(ii) of this section is submitted by the network pharmacy, a claim becomes a clean claim within ten (10) days if the pharmacy benefits manager does not provide notice to the submitting network pharmacy of any remaining defect or impropriety in the claim or of any new defect or impropriety in the additional information submitted.(B) A pharmacy benefits manager shall not provide notice of a new deficiency or impropriety in the claim that could have been identified by the pharmacy benefits manager in the original claim submission under this subsection.
(A) After the additional information described in subdivision (b)(2)(B)(ii) of this section is submitted by the network pharmacy, a claim becomes a clean claim within ten (10) days if the pharmacy benefits manager does not provide notice to the submitting network pharmacy of any remaining defect or impropriety in the claim or of any new defect or impropriety in the additional information submitted.
(B) A pharmacy benefits manager shall not provide notice of a new deficiency or impropriety in the claim that could have been identified by the pharmacy benefits manager in the original claim submission under this subsection.
(c) A claim submitted to a pharmacy benefits manager that is not paid by the pharmacy benefits manager within the time frame specified in subdivision (a)(1) or subdivision (a)(2) of this section or is not contested by the pharmacy benefits manager within the time frame specified in subdivision (b)(2) of this section shall be:(1) Deemed to be a clean claim; and(2) Paid by the pharmacy benefits manager according to subsection (a) of this section.
(1) Deemed to be a clean claim; and
(2) Paid by the pharmacy benefits manager according to subsection (a) of this section.
(d) A payment of a clean claim under subdivision (c)(2) of this section is considered to have been made on the date that:(1) The payment is transferred, for an electronic claim; or(2) The payment is submitted to the United States Postal Service or common carrier for delivery, for any other claim.
(1) The payment is transferred, for an electronic claim; or
(2) The payment is submitted to the United States Postal Service or common carrier for delivery, for any other claim.
(e) (1) (A) A pharmacy benefits manager shall pay a penalty of twelve percent (12%) per month for a late payment of claims to the contracted pharmacist or pharmacy.(B) The penalty described under subdivision (e)(1)(A) of this section begins the day after the required payment date and ends on the date on which the proper payment for the clean claim is made.(2) (A) As determined by the Insurance Commissioner, a pharmacy benefits manager shall not be penalized or required to pay interest under subdivision (e)(1) of this section in exigent circumstances that prevent the timely processing of claims, including natural disasters and other unique and unexpected events, unless they involve a cybersecurity breach or a data security issue with the pharmacy benefits manager or healthcare payor.(B) A cybersecurity breach or a data security issue involving the pharmacy benefits manager or the healthcare payor that delays payment to a pharmacist or a pharmacy is subject to interest payments.
(1) (A) A pharmacy benefits manager shall pay a penalty of twelve percent (12%) per month for a late payment of claims to the contracted pharmacist or pharmacy.(B) The penalty described under subdivision (e)(1)(A) of this section begins the day after the required payment date and ends on the date on which the proper payment for the clean claim is made.
(A) A pharmacy benefits manager shall pay a penalty of twelve percent (12%) per month for a late payment of claims to the contracted pharmacist or pharmacy.
(B) The penalty described under subdivision (e)(1)(A) of this section begins the day after the required payment date and ends on the date on which the proper payment for the clean claim is made.
(2) (A) As determined by the Insurance Commissioner, a pharmacy benefits manager shall not be penalized or required to pay interest under subdivision (e)(1) of this section in exigent circumstances that prevent the timely processing of claims, including natural disasters and other unique and unexpected events, unless they involve a cybersecurity breach or a data security issue with the pharmacy benefits manager or healthcare payor.(B) A cybersecurity breach or a data security issue involving the pharmacy benefits manager or the healthcare payor that delays payment to a pharmacist or a pharmacy is subject to interest payments.
(A) As determined by the Insurance Commissioner, a pharmacy benefits manager shall not be penalized or required to pay interest under subdivision (e)(1) of this section in exigent circumstances that prevent the timely processing of claims, including natural disasters and other unique and unexpected events, unless they involve a cybersecurity breach or a data security issue with the pharmacy benefits manager or healthcare payor.
(B) A cybersecurity breach or a data security issue involving the pharmacy benefits manager or the healthcare payor that delays payment to a pharmacist or a pharmacy is subject to interest payments.
(f) (1) A pharmacy benefits manager shall pay a clean claim submitted electronically by an electronic transfer of funds if the submitting network pharmacy so requests or has so requested previously that contract year.(2) If the payment is made electronically, remittance may also be made electronically by the pharmacy benefits manager.
(1) A pharmacy benefits manager shall pay a clean claim submitted electronically by an electronic transfer of funds if the submitting network pharmacy so requests or has so requested previously that contract year.
(2) If the payment is made electronically, remittance may also be made electronically by the pharmacy benefits manager.
(g) (1) This section does not prohibit or limit a claim or action that an individual or organization has against a pharmacy, provider, or pharmacy benefits manager that is not covered by the subject matter of this section.(2) A pharmacy benefits manager shall not retaliate against an individual, pharmacy, or provider for exercising a right of action under subdivision (g)(1) of this section, as consistent with applicable federal or state law.
(1) This section does not prohibit or limit a claim or action that an individual or organization has against a pharmacy, provider, or pharmacy benefits manager that is not covered by the subject matter of this section.
(2) A pharmacy benefits manager shall not retaliate against an individual, pharmacy, or provider for exercising a right of action under subdivision (g)(1) of this section, as consistent with applicable federal or state law.