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

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.