Title 58 — INSURANCE

The pharmacy audit integrity program is hereby established to provide standards for an audit of pharmacy records carried out by a pharmacy benefits manager or any entity that represents the pharmacy benefits manager. Source: SL 2013, ch 254 , § 1.

If contractually required, an auditing entity shall provide a copy of the claims included in the audit to the plan sponsor, and any recouped money shall be returned to the plan sponsor. Source: SL 2013, ch 254 , § 10.

The provisions of this chapter do not apply to any investigative audit that involves fraud, willful misrepresentation, or on any audit completed by the State of South Dakota on health care programs operated by the state. Source: SL 2013, ch 254 , § 11.

In addition to the remedies otherwise provided for in this chapter, in chapter 58-29E , or under general South Dakota law, any pharmacy subject to an audit procedure may bring a civil action to enforce the provisions of this chapter and to seek damages from the pharmacy benefits …

Term used in this chapter mean: (1) "Entity," a pharmacy benefits manager or any person or organization that represents these companies, groups, or organizations in any capacity; (2) "Plan sponsor," the employer in the case of an employee benefit plan established or maintained by…

The pharmacy benefits manager shall disclose an amendment to the pharmacy audit terms in a contract between a pharmacy and a pharmacy benefits manager to the pharmacy at least sixty days prior to the effective date of the proposed change. Source: SL 2013, ch 254 , § 3.

Unless otherwise prohibited by federal statutes or regulations, any entity conducting a pharmacy audit shall: (1) Give a pharmacy a minimum fourteen days written notice before conducting initial on-site audit; (2) Conduct an audit that involves clinical or professional judgment i…

Unless otherwise prohibited by federal statutes or regulations, for any entity conducting a pharmacy audit the following audit items apply: (1) The period covered by the audit may not exceed twenty-four months from the date that the claim was submitted to or adjudicated by the en…

For recoupment or chargeback, the following criteria apply: (1) Audit parameters shall consider consumer-oriented parameters based on manufacturer listings; (2) A pharmacy's usual and customary price for compounded medications is considered the reimbursable cost unless the pricin…

To validate the pharmacy record and delivery, the pharmacy may use authentic and verifiable statements or records including medication administration records of a nursing home, assisted living facility, hospital, physician, or other authorized practitioner or additional audit doc…

A preliminary audit report shall be delivered to the pharmacy within sixty days after the conclusion of the audit. A pharmacy shall be allowed at least forty-five days following receipt of the preliminary audit, to provide documentation to address any discrepancy found in the aud…

The entity conducting the audit shall establish a written appeals process which shall include appeals of preliminary reports and final reports. Source: SL 2013, ch 254 , § 9.