(a) (1) A contracting entity shall provide a reasonable administrative appeal procedure to allow a healthcare provider to challenge the reimbursement for a specific drug as being below the healthcare provider's drug acquisition cost.(2) The reasonable administrative appeal procedure under subdivision (a)(1) of this section shall include:(A) A dedicated telephone number, email address, and website for the purpose of submitting an administrative appeal;(B) The ability to submit an administrative appeal directly to the healthcare insurer or health benefit plan; and(C) The ability to file an administrative appeal no less than sixty (60) business days following the adjudication of a claim.
(1) A contracting entity shall provide a reasonable administrative appeal procedure to allow a healthcare provider to challenge the reimbursement for a specific drug as being below the healthcare provider's drug acquisition cost.
(2) The reasonable administrative appeal procedure under subdivision (a)(1) of this section shall include:(A) A dedicated telephone number, email address, and website for the purpose of submitting an administrative appeal;(B) The ability to submit an administrative appeal directly to the healthcare insurer or health benefit plan; and(C) The ability to file an administrative appeal no less than sixty (60) business days following the adjudication of a claim.
(A) A dedicated telephone number, email address, and website for the purpose of submitting an administrative appeal;
(B) The ability to submit an administrative appeal directly to the healthcare insurer or health benefit plan; and
(C) The ability to file an administrative appeal no less than sixty (60) business days following the adjudication of a claim.
(b) If a challenge is made under subsection (a) of this section, within thirty (30) business days of receipt of the challenge, the contracting entity shall:(1) If the appeal is upheld:(A) Make the change in the reimbursement rate to at least one hundred ten percent (110%) of the healthcare provider's drug acquisition cost;(B) Reprocess, or cause the healthcare insurer or health benefit plan to reprocess, the claim in question at the reimbursement rate established under subdivision (b)(1)(A) of this section; and(C) Process, or cause the healthcare insurer or health benefit plan to reprocess, any subsequent claim for the same drug, as identified by the National Drug Code or Healthcare Common Procedure Coding System, at the reimbursement rate established in subdivision (b)(1)(A) of this section; or(2) If the appeal is denied, provide the challenging healthcare provider with the specific information about the basis for the denial, including without limitation any additional information necessary to establish the drug acquisition cost.
(1) If the appeal is upheld:(A) Make the change in the reimbursement rate to at least one hundred ten percent (110%) of the healthcare provider's drug acquisition cost;(B) Reprocess, or cause the healthcare insurer or health benefit plan to reprocess, the claim in question at the reimbursement rate established under subdivision (b)(1)(A) of this section; and(C) Process, or cause the healthcare insurer or health benefit plan to reprocess, any subsequent claim for the same drug, as identified by the National Drug Code or Healthcare Common Procedure Coding System, at the reimbursement rate established in subdivision (b)(1)(A) of this section; or
(A) Make the change in the reimbursement rate to at least one hundred ten percent (110%) of the healthcare provider's drug acquisition cost;
(B) Reprocess, or cause the healthcare insurer or health benefit plan to reprocess, the claim in question at the reimbursement rate established under subdivision (b)(1)(A) of this section; and
(C) Process, or cause the healthcare insurer or health benefit plan to reprocess, any subsequent claim for the same drug, as identified by the National Drug Code or Healthcare Common Procedure Coding System, at the reimbursement rate established in subdivision (b)(1)(A) of this section; or
(2) If the appeal is denied, provide the challenging healthcare provider with the specific information about the basis for the denial, including without limitation any additional information necessary to establish the drug acquisition cost.
(c) If an appeal is upheld under subdivision (b)(1) of this section, the rate established by the appeal shall remain in place:(1) For an appeal initiated before the last month of a contracting entity's fiscal quarter, until the end of the fiscal quarter in which the appeal was initiated; and(2) For an appeal initiated within the last month of a contracting entity's fiscal quarter, until the end of the fiscal quarter following the quarter in which the appeal was initiated.
(1) For an appeal initiated before the last month of a contracting entity's fiscal quarter, until the end of the fiscal quarter in which the appeal was initiated; and
(2) For an appeal initiated within the last month of a contracting entity's fiscal quarter, until the end of the fiscal quarter following the quarter in which the appeal was initiated.
(d) (1) A healthcare provider may provide a quarterly notice to a contracting entity of all drugs with an acquisition cost below the contracted reimbursement rate.(2) If a contracting entity receives notice under subdivision (d)(1) of this section, the contracting entity may change the reimbursement rates to at least one hundred ten percent (110%) of the healthcare provider's drug acquisition cost without an appeal under this section.
(1) A healthcare provider may provide a quarterly notice to a contracting entity of all drugs with an acquisition cost below the contracted reimbursement rate.
(2) If a contracting entity receives notice under subdivision (d)(1) of this section, the contracting entity may change the reimbursement rates to at least one hundred ten percent (110%) of the healthcare provider's drug acquisition cost without an appeal under this section.