Prescription benefit managers would face deadlines for paying pharmacies

Companies that manage prescription drug benefits would have to pay complete pharmacy claims within set deadlines. Complete claims have no defects, missing required documents, or other problems that prevent timely payment. Investigative audits prompted by signs of fraud or other listed misconduct would be excluded. The deadlines would take effect on the first day of the ninth month after enactment.

Benefit managers would have to list claim problems and any information needed to fix them. Certain misconduct investigations would be excluded. After additional information arrives, a claim would count as complete within 10 days unless the manager reports remaining problems or new problems in that information. Managers could not later raise problems they could have spotted in the original claim. The initial notice periods would run from the date the manager receives the claim.

Benefit managers would pay pharmacies a penalty of 12% of the late payment per month. The penalty would cover late pharmacy claim payments, with an exception for certain misconduct investigations. Urgent, unexpected events, such as natural disasters, must prevent timely claim processing to excuse the penalty. The manager’s own cybersecurity or data security problems would not excuse the penalty. Penalties would run from the day after payment was due through the day proper payment is made.