760 Ind. Admin. Code 5-3-6

Current through October 31, 2024

Section 760 IAC 5-3-6 - Overpayment and underpayment audit findings

Authority: IC 27-1-24.5-20

Affected: IC 27-1-24.5-22

Sec. 6.

An audit finding of an overpayment or underpayment of a claim:

(1) must be based on an actual overpayment or underpayment of an audited claim discovered to include a recoverable error;

(2) must not be based on a projection that is based on the number of:

(A) patients who:

(i) have similar diagnoses; and

(ii) are served by the pharmacy; or

(B) prescriptions for or refills of similar prescription drugs that are dispensed by the pharmacy; and

(3) must not include dispensing fees unless a prescription was not actually dispensed, the prescriber denied authorization, the prescription dispensed was a medication error by the pharmacy, or the identified overpayment is solely based on an extra dispensing fee.

760 IAC 5-3-6

Department of Insurance; 760 IAC 5-3-6; filed 2/23/2023, 9:48 a.m.: 20230322-IR-760220287FRA