Claims Disputes

CLAIMS/PRICING DISPUTE INFORMATION FOR PHARMACIES

GENERAL CLAIM DISPUTES:

In the event a Pharmacy wishes to dispute a claim due to an alleged discrepancy, error, or noncompliance with regard to terms of the Pharmacy Agreement, Pharmacy must notify PBM in writing within sixty (60) days of the date of fill, or in accordance with the Agreement or state or federal laws, if applicable. The claim dispute notification must include Pharmacy’s NCPDP or NPI number, Covered Person’s ID number, prescription number, date of fill, claim reference number and detailed information stating the reason for the dispute. PBM shall have thirty (30) business days to respond to the notification, provided all documentation/information is obtained from the Pharmacy. In the event PBM requests additional documentation/information, the Pharmacy must comply in a timely manner to provide PBM the requested information. Once the additional requested information is received from the Pharmacy, PBM has thirty (30) business days to research and respond to the Pharmacy’s appeal. 

Claim dispute notifications should be emailed to network@procarerx.com. 

PBM’s appeals process provides three (3) levels of review: 

1. First Level Appeal – PBM’s Clinical team 
2. Second Level Appeal – PBM’s Clinical team [2] 
3. Third (and final) Level Appeal – a contracted external review organization (“ERO”) Expedited appeals are determined and verbal notification to the Member and Prescriber is provided within 72 hours from receipt of request and written notification within three (3) calendar days of request. Non-expedited (standard) appeals are responded to within 30 calendar days of request. This policy is available to Members and Prescribers upon request.

CLAIM APPEALS PROCEDURE: 

If the initial coverage decision is denied and First Level Appeals are not delegated to PBM, the notification will refer the Member to their respective health plan. The First Level Appeals process shall be as follows: 

1. When the appeal is received in writing or telephonically, the request shall be forwarded to PBM’s Clinical team for review. 
2. PBM’s Clinical team may obtain additional information from the treating Prescriber and or claim information, and other such clinical materials, including FDA approved package inserts, industry clinical journals, and other information that may be relevant to making an impartial decision. 
3. PBM’s Clinical team shall review the appeal and document their decision in writing. 
4. If the decision is to deny, the Member and Prescriber are notified of the denial in writing, along with the process to file a secondary appeal if the Member/Prescriber does not agree with the findings. 

If secondary appeals are not delegated by the Client to PBM, the appeal letter will refer the Member to their health plan. If the appeal is overturned, the Member and Prescriber are notified in writing. PBM’s Clinical team will add a rule into the System allowing the claim to pay. 

The Second Level Appeals process shall be as follows: 

1. The case, including all documentation in the previous steps, shall be submitted to PBM’s Clinical Pharmacist. 
2. PBM’s Clinical team [2] may obtain additional information from the treating Prescriber and or claim information and other such clinical materials, including FDA approved package inserts, industry clinical journals, and other information that may be relevant to making an impartial decision. 
3. A review shall be performed by PBM’s Clinical Pharmacist, and their decision is documented in writing. 
4. If the First Level Appeal is overturned, the Member and Prescriber are notified in writing. 
5. If the decision is to uphold the original denial, the Member and Prescriber are notified of the denial in writing, along with the process to file a final appeal if the Member/Prescriber does not agree with the findings. 

The Third (and final) Level Appeals process shall be as follows: 

1. The case, including all documentation in the previous steps, will be submitted to a contracted external independent review company for review. 
2. A review shall be performed by the contracted external independent review company, and their final decision is documented in writing. 
3. Client shall be notified in a summary document of the final decision by the contracted external independent review company. 
4. In accordance with the arrangement between PBM and the Client, the Member shall be notified of the final decision of the contracted external independent review company. 
5. For health plan Clients and other approved entities that may accept PHI, the documentation provided by PBM may include Patient-specific information. Appeal documentation is managed electronically. 

The documentation of appeals includes the following: 

• Consumer demographics. 
• Correspondence from the Consumer/Prescriber. 
• Dates (open, reviewed, and closed). 
• Name and credentials of clinical peer. 
• Clinical review criteria if a non-certification is determined. 

Appeal reports are submitted to the Quality Committee on a quarterly basis. NOTE: All appeals are reviewed by Pharmacists or Physicians as permitted by state appeal laws, who were not involved in the original denial decision. Neither the individual who made the original non-certification, nor the subordinate of such individual is involved in the appeal. PBM is committed to using good clinical practice guidelines, and uses information derived from a review of currently available clinical information, including clinical outcome studies in the peer-reviewed published literature, regulatory status of the procedure, evidence-based guidelines of public health research agencies, views of practitioners practicing in relevant clinical areas, and other relevant factors. PBM makes no representation and accepts no liability with respect to the content of any external information cited or relied upon in establishing the clinical practice guidelines. The description, background, and positions reflected in the clinical practice guidelines, including any reference to a specific Provider, product, process, or Service by name, trademark, or manufacturer, constitutes PBM’s opinion and are made without intent to defame. PBM further makes no representation that these opinions are endorsed by any healthcare Provider or healthcare Provider society, and reserves the right to revise the clinical practice guidelines as clinical information changes. The conclusion that a particular drug or Service is acceptable does not constitute a representation or warranty that this Drug Service is covered for a Member’s benefit plan. The Member’s benefit plan determines coverage. 

GENERIC DRUG (MAC) APPEALS: 

PBM is committed to reviewing fully completed and submitted MAC appeals in a timely manner, or in accordance with state guidelines. Requirements for MAC appeals may be found on the Generic Pricing Appeal Form located on the Pharmacy Portal. 

Pharmacy agrees not to delay, withhold, or affect Covered Person access to Services in the event a MAC appeal is generated by Pharmacy. In addition, Pharmacy shall not involve the Covered Person or Covered Person’s Plan Sponsor of such reimbursement disputes. 

An independent Pharmacy holding a direct Agreement with PBM may submit a MAC appeal directly to PBM via reimbursement@procarerx.com. An independent Pharmacy under a third-party affiliation (“PSAO”) or chain agreement must direct all MAC inquiries to their affiliation for proper handling, unless otherwise indicated by PBM. 

A MAC appeal sent to PBM by an affiliated independent Pharmacy will not be reviewed unless prior permission has been granted solely by PBM. It is the expectation of PBM that all MAC appeals sent by a chain affiliation are fully reviewed and screened prior to submitting to PBM for review. Appeals will not be reviewed for claims reimbursed at U&C, submitted ingredient cost, claims reimbursed at AWP discounts, or Brand Drug Claims. Duplicate claims will not be reviewed and are limited to one (1) individual claim reference number per appeal. Appeals submitted without the required supporting documentation, such as Pharmacy name, Pharmacy NCPDP/NPI, BIN, prescription number, fill date, Drug Product NDC, and acquisition cost shall be considered incomplete and will not be reviewed until all information is received. 

All completed appeals must be emailed to reimbursement@procarerx.com within sixty (60) days of the actual claim fill date, or per federal and state guidelines. Reviews and final determination of accepted MAC appeals shall average five (5) to seven (7) business days, and appeals will not pend for more than fourteen (14) calendar days, unless a shorter timeframe is stipulated by state law. If PBM denies a MAC appeal, PBM will provide the Pharmacy with the national drug code number (NDC) of a prescription drug that is available from a national or regional wholesaler operating and licensed in the state where the Pharmacy is located and the reason for PBM’s determination. 

If PBM finds in favor of a Pharmacy for a MAC appeal, PBM will: 

1. Change the MAC price of the appealed drug as of the initial claim fill date; 
2. Adjust the MAC price of the appealed drug for the appealing Pharmacy and other similarly situated Pharmacies; 
3. Timely notify the appealing Pharmacy and similarly situated Pharmacies that they can reverse and resubmit claims for the appealed drug; 
4. Make a retroactive price adjustment for the appealed drug in the next payment cycle; and 
5. Adjust resubmitted claims based on the adjusted MAC price, when applicable.

PBM’s appeal process applies to all prescription drugs or devices in Tennessee for which a pharmacy alleges it did not receive its actual cost.

Important Contact Information:

∙ Claims-related Issues or Questions: 800-699-3542

∙ Pharmacy Dispute Resolution: network@procarerx.com 

∙ Generic Pricing Appeals (MAC) Inquiries: reimbursement@procarerx.com

∙ PBM Pharmacy Portal: https://mc-rx.com (appeals can be submitted here too)