Md. Code Regs. 31.10.47.04

Current through Register Vol. 51, No. 18, September 6, 2024

Section 31.10.47.04 - Internal Appeal Procedures

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.

Md. Code Regs. 31.10.47.04

Regulation .04 adopted effective 47:6 Md. R. 343, eff. 3/23/2020