Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.47 - Cost Pricing and Reimbursement Other than MAC
Section 31.10.47.04 - Internal Appeal Procedures
Universal Citation: MD Code Reg 31.10.47.04
Current through Register Vol. 51, No. 19, September 20, 2024
A. Each PBM subject to this chapter shall establish written procedures to investigate and resolve disputes filed by a contracted pharmacy.
B. The internal appeal procedures established by the PBM shall:
(1) Be in writing; and
(2) Contain administrative processes and safeguards designed to ensure and verify that the pricing was determined in accordance with the participating pharmacy contract and Maryland law, and that the contract provisions have not been applied in an arbitrary or capricious manner.
C. The procedures established by the PBM may not require:
(1) More than one appeal before filing a complaint with the Commissioner; or
(2) The payment of a fee to file an appeal.
D. The internal appeal procedures established by the PBM shall be provided to the Commissioner on request.
E. The internal procedures established by the PBM shall:
(1) Provide written notice of the PBM's decision no later than 90 days after receipt of the appeal or review;
(2) Pay any money due within 30 days after the internal review is complete; and
(3) Provide a contracted pharmacy:
(a) 21 days to file an appeal after the contracted pharmacy is charged a direct or indirect remuneration fee; or
(b) A minimum of 180 days to request review of the reimbursement amount of a submitted claim.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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