Section 1369.259 - Calculation of Recoupment; Use of Extrapolation Prohibited(a) A health benefit plan issuer or pharmacy benefit manager may not calculate the amount of a recoupment based on:(1) an absence of documentation the pharmacist or pharmacy is not required by applicable federal laws and regulations and state laws and rules to maintain; or(2) an error that does not result in actual financial harm to the patient or enrollee, the health benefit plan issuer, or the pharmacy benefit manager.(b) A health benefit plan issuer or pharmacy benefit manager may not require extrapolation audits as a condition of participation in a contract, network, or program for a pharmacist or pharmacy.(c) A health benefit plan issuer or pharmacy benefit manager may not use extrapolation to complete an on-site audit or a desk audit of a pharmacist or pharmacy. Notwithstanding Subsection (a)(2), the amount of a recoupment must be based on the actual overpayment or underpayment and may not be based on an extrapolation.(d) A health benefit plan issuer or pharmacy benefit manager may not include a dispensing fee amount in the calculation of an overpayment unless:(1) the fee was a duplicate charge;(2) the prescription for which the fee was charged: (A) was not dispensed; or(B) was dispensed: (i) without the prescriber's authorization;(ii) to the wrong patient; or(iii) with the wrong instructions; or(3) the wrong drug was dispensed.Tex. Ins. Code § 1369.259
Added by Acts 2013, 83rd Leg. - Regular Session, ch. 915,Sec. 1, eff. 9/1/2013.