House committee substitute makes the following changes to 1st edition.
Amends proposed GS 90-85.50, specifying that a pharmacy has the right to at least 21 days advance notice (was, 30 days) of the initial on-site audit for each audit cycle. Clarifies that the pharmacy has the right to have any audit that involves clinical or professional judgment conducted with a pharmacist employed or working under contract with the auditing entity, and the right to have the auditing entity provide, upon request, all records related to the audit if required under the contract. Clarifies that the audit is limited to claims identified by prescription numbers if the audit is conducted for an identified problem; otherwise the audit is limited to 40 selected prescriptions (rather than 25 randomly selected prescriptions). States that the pharmacy will not be subject to the initiation or scheduling of audits during the first five (was, seven) calendar days of any month due to the high volume of prescriptions filled during that time, without express consent; requires the pharmacy to cooperate with the auditor to establish an alternate date if necessary. Clarifies that a final audit report must be delivered to the pharmacy within 90 days (was, six months) after the end of the specified appeals period. Amends proposed GS 90-85.51, clarifying that each entity conducting an audit must provide a copy of the audit findings after completion of the appeals process, if required by the contract. Makes other clarifying changes.
Adds a section directing a provider to submit to the Division of Medical Assistance a written request for a Reconsideration Review within 30 days of receipt of notice of tentative decision. States that failure to request the Review in the specified time will result in the implementation of the tentative decision as the final decision. Specifies that any provider who received notice of a tentative decision on or after March 1, 2011, is eligible to resubmit a request for a Review within 30 working days of this act becoming law. Directs the Department of Health and Human Services to amend any rule in conflict with this provision. Makes this provision effective when it becomes law. Makes a conforming change to the title.