Section 51488 - Pharmaceutical Postservice -Postpayment On-Site Reviews Including Clinics with Special Permits(a) The Department, during on-site reviews of pharmaceutical providers, including clinics with special permits, may review the records of the provider related to the provision of Medi-Cal services to determine compliance with Medi-Cal statutes and regulations. The Department may consider the following in deciding that a provider has received an overpayment: (1) The drug was ordered or authorized by a licensed prescriber ineligible to participate in the Medi-Cal program.(2) The dispensed drug, strength and quantity were not the same as the drug, strength and quantity that were ordered or authorized.(3) The drug dispensed was not a covered benefit.(4) The Medi-Cal program was inappropriately charged.(5) The recipient was ineligible to receive Medi-Cal benefits.(6) The drug was dispensed contrary to the provisions of Section 51513.6.(b) The Department shall determine whether a service was provided in compliance with Medi-Cal statutes and regulations. Apparent violations of non-Medi-Cal statutes or regulations shall be referred to appropriate agencies.(c) The Department shall have the burden of demonstrating that noncompliance with Medi-Cal statutes or regulations has occurred. This burden shall be met if the determination is based upon information appearing on records maintained by the provider pursuant to Section 51476 and 51476.1 of these regulations or evidence from other sources. The Department shall consider evidence supplied by the provider from other sources in arriving at its determination.(d) The results of the on-site review should serve the additional purpose of directing the provider to the Departmental policies and requirements as they apply to audit issues identified.Cal. Code Regs. Tit. 22, § 51488
1. New section filed 4-9-80; effective thirtieth day thereafter (Register 80, No. 15).
2. New subsection (a)(6) filed 6-1-83 as an emergency; effective upon filing (Register 83, No. 24). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 9-29-83.
3. Certificate of Compliance as to 6-1-83 order transmitted to OAL 9-29-83; corrected Certificate of Compliance transmitted to OAL 10-31-83 and filed 10-31-83 and refiled 11-1-83 with original Certificate of Compliance (Register 83, No. 44).
4. Amendment of section heading, subsection (a) and NOTE filed 1-6-94; operative 2-7-94 (Register 94, No. 1). Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code; and Chapter 328, Section 57, and Chapter 1594, Section 87, Statutes of 1982. Reference: Sections 14053, 14105.3, 14107, 14124.1, 14132, 14133 and 14184, Welfare and Institutions Code; and Sections 4063 and 4063.7, Business and Professions Code.
1. New section filed 4-9-80; effective thirtieth day thereafter (Register 80, No. 15).
2. New subsection (a)(6) filed 6-1-83 as an emergency; effective upon filing (Register 83, No. 24). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 9-29-83.
3. Certificate of Compliance as to 6-1-83 order transmitted to OAL 9-29-83; corrected Certificate of Compliance transmitted to OAL 10-31-83 and filed 10-31-83 and refiled 11-1-83 with original Certificate of Compliance (Register 83, No. 44).
4. Amendment of section heading, subsection (a) and Note filed 1-6-94; operative 2-7-94 (Register 94, No. 1).