reglab/housing_qa huggingface dataset:
TX Ins Code § 1369.212 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter E. -1. Coverage of Prescription Drugs for Stage-Four Advanced, Metastatic Cancer|Section 1369.212. Applicability of Subchapter

Sec. 1369.212.  APPLICABILITY OF SUBCHAPTER.  (a)  This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses or pharmacy benefits incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is issued by:(1)  an insurance company;(2)  a group hospital service corporation operating under Chapter 842;(3)  a health maintenance organization operating under Chapter 843;(4)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;(5)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;(6)  a stipulated premium company operating under Chapter 884;(7)  a fraternal benefit society operating under Chapter 885;(8)  a Lloyd's plan operating under Chapter 941; or(9)  an exchange operating under Chapter 942.(b)  Notwithstanding any other law, this subchapter applies to:(1)  a small employer health benefit plan subject to Chapter 1501, including coverage provided through a health group cooperative under Subchapter B of that chapter;(2)  a standard health benefit plan issued under Chapter 1507;(3)  a basic coverage plan under Chapter 1551;(4)  a basic plan under Chapter 1575;(5)  a primary care coverage plan under Chapter 1579;(6)  a plan providing basic coverage under Chapter 1601;(7)  health benefits provided by or through a church benefits board under Subchapter I, Chapter 22, Business Organizations Code;(8)  group health coverage made available by a school district in accordance with Section 22.004, Education Code;(9)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code;(10)  the child health plan program under Chapter 62, Health and Safety Code;(11)  a regional or local health care program operated under Section 75.104, Health and Safety Code; and(12)  a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code.(c)  This subchapter applies to coverage under a group health benefit plan provided to a resident of this state regardless of whether the group policy, agreement, or contract is delivered, issued for delivery, or renewed in this state.|Added by Acts 2019, 86th Leg., R.S., Ch. 1350 (H.B. 1584), Sec. 1, eff. September 1, 2019.|
TX Ins Code § 1369.213 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter E. -1. Coverage of Prescription Drugs for Stage-Four Advanced, Metastatic Cancer|Section 1369.213. Prohibited Conduct

Sec. 1369.213.  PROHIBITED CONDUCT.  (a)  A health benefit plan that provides coverage for stage-four advanced, metastatic cancer and associated conditions may not require, before the health benefit plan provides coverage of a prescription drug approved by the United States Food and Drug Administration, that the enrollee:(1)  fail to successfully respond to a different drug; or(2)  prove a history of failure of a different drug.(b)  This section applies only to a drug the use of which is:(1)  consistent with best practices for the treatment of stage-four advanced, metastatic cancer or an associated condition;(2)  supported by peer-reviewed, evidence-based literature; and(3)  approved by the United States Food and Drug Administration.|Added by Acts 2019, 86th Leg., R.S., Ch. 1350 (H.B. 1584), Sec. 1, eff. September 1, 2019.|
TX Ins Code § 1369.251 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.251. Definitions

Sec. 1369.251.  DEFINITIONS.  In this subchapter:(1)  "Desk audit" means an audit conducted by a health benefit plan issuer or pharmacy benefit manager at a location other than the location of the pharmacist or pharmacy.  The term includes an audit performed at the offices of the plan issuer or pharmacy benefit manager during which the pharmacist or pharmacy provides requested documents for review by hard copy or by microfiche, disk, or other electronic media.  The term does not include a review conducted not later than the third business day after the date a claim is adjudicated provided recoupment is not demanded.(2)  "Extrapolation" means a mathematical process or technique used by a health benefit plan issuer or pharmacy benefit manager that administers pharmacy claims for a health benefit plan issuer in the audit of a pharmacy or pharmacist to estimate audit results or findings for a larger batch or group of claims not reviewed by the plan issuer or pharmacy benefit manager.(3)  "Health benefit plan" means a plan that provides benefits for medical, surgical, or other treatment expenses incurred as a result of a health condition, a mental health condition, an accident, sickness, or substance abuse, including:(A)  an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is issued by:(i)  an insurance company;(ii)  a group hospital service corporation operating under Chapter 842;(iii)  a health maintenance organization operating under Chapter 843;(iv)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;(v)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;(vi)  a stipulated premium company operating under Chapter 884;(vii)  a fraternal benefit society operating under Chapter 885;(viii)  a Lloyd's plan operating under Chapter 941; or(ix)  an exchange operating under Chapter 942;(B)  a small employer health benefit plan written under Chapter 1501; or(C)  a health benefit plan issued under Chapter 1551, 1575, 1579, or 1601.(4)  "On-site audit" means an audit that is conducted at:(A)  the location of the pharmacist or pharmacy; or(B)  another location at which the records under review are stored.(5)  "Pharmacy benefit manager" has the meaning assigned by Section 4151.151.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.252 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.252. Exceptions to Applicability of Subchapter

Sec. 1369.252.   EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.  This subchapter does not apply to an issuer or provider of health benefits under or a pharmacy benefit manager administering pharmacy benefits under:(1)  the state Medicaid program;(2)  the federal Medicare program;(3)  the state child health plan or health benefits plan for children under Chapter 62 or 63, Health and Safety Code;(4)  the TRICARE military health system;(5)  a workers' compensation insurance policy or other form of providing medical benefits under Title 5, Labor Code; or(6)  a self-funded health benefit plan as defined by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.).|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.253 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.253. Conflict With Other Laws

Sec. 1369.253.  CONFLICT WITH OTHER LAWS.  If there is a conflict between this subchapter and a provision of Chapter 843 or 1301 related to a pharmacy benefit manager, this subchapter prevails.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.255 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.255. Completion of Audit

Sec. 1369.255.  COMPLETION OF AUDIT.  An audit of a claim under Section 1369.254 must be completed on or before the one-year anniversary of the date the claim is received by the health benefit plan issuer or pharmacy benefit manager.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.256 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.256. Audit Requiring Professional Judgment

Sec. 1369.256.  AUDIT REQUIRING PROFESSIONAL JUDGMENT.  A health benefit plan issuer or pharmacy benefit manager that conducts an on-site audit or a desk audit involving a pharmacist's clinical or professional judgment must conduct the audit in consultation with a licensed pharmacist.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.257 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.257. Access to Pharmacy Area

Sec. 1369.257.  ACCESS TO PHARMACY AREA.  A health benefit plan issuer or pharmacy benefit manager that conducts an on-site audit may not enter the pharmacy area unless escorted by an individual authorized by the pharmacist or pharmacy.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.258 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.258. Validation Using Certain Records Authorized

Sec. 1369.258.  VALIDATION USING CERTAIN RECORDS AUTHORIZED.  A pharmacist or pharmacy that is being audited may:(1)  validate a prescription, refill of a prescription, or change in a prescription with a prescription that complies with applicable federal laws and regulations and state laws and rules adopted under Section 554.051, Occupations Code; and(2)  validate the delivery of a prescription with a written record of a hospital, physician, or other authorized practitioner of the healing arts.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.2581 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.2581. Audit Discrepancies; Wholesale Invoices

Sec. 1369.2581.  AUDIT DISCREPANCIES; WHOLESALE INVOICES.  (a)  A health benefit plan issuer or pharmacy benefit manager that audits wholesale invoices during an audit of a pharmacist or pharmacy may not audit the pharmacy claims of another health benefit plan or pharmacy benefit manager.(b)  A health benefit plan issuer or pharmacy benefit manager shall reverse a finding of a discrepancy if:(1)  the National Drug Code for the dispensed drug is in a quantity that is a subunit or multiple of the drug purchased by the pharmacist or pharmacy as supported by a wholesale invoice;(2)  the pharmacist or pharmacy dispensed the correct quantity of the drug according to the prescription; and(3)  the drug dispensed by the pharmacist or pharmacy shares all but the last two digits of the National Drug Code of the drug reflected on the supplier invoice.(c)  A health benefit plan issuer or pharmacy benefit manager must accept as evidence to support the validity of a pharmacy claim related to a dispensed drug:(1)  subject to validation, including validation by pharmacy purchase order and payment of a supplier invoice, copies of supplier invoices in the pharmacist's or pharmacy's possession, including:(A)  supplier invoices issued before the date the drug was dispensed and not earlier than 60 days before the first day of the audit period; and(B)  invoices and any supporting documents from any supplier authorized by federal or state law to transfer ownership of the drug acquired by the pharmacist or pharmacy; and(2)  reports required by any state board or agency.(d)  A health benefit plan issuer or pharmacy benefit manager must provide, not later than the fifth business day after the date of a request by the pharmacist or pharmacy, any supporting documents the pharmacist's or pharmacy's suppliers provided to the health benefit plan issuer or pharmacy benefit manager.|Added by Acts 2019, 86th Leg., R.S., Ch. 481 (H.B. 1455), Sec. 1, eff. September 1, 2019.|
TX Ins Code § 1369.259 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.259. Calculation of Recoupment; Use of Extrapolation Prohibited

Sec. 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.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.260 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.260. Clerical or Recordkeeping Error; Fraud Allegation

Sec. 1369.260.  CLERICAL OR RECORDKEEPING ERROR; FRAUD ALLEGATION.  (a) An unintentional clerical or recordkeeping error, such as a typographical error, scrivener's error, or computer error, found during an on-site audit or a desk audit:(1)  is not prima facie evidence of fraud or intentional misrepresentation; and(2)  may not be the basis of a recoupment unless the error results in actual financial harm to a patient or enrollee, health benefit plan issuer, or pharmacy benefit manager.(b)  If the health benefit plan issuer or pharmacy benefit manager alleges that the pharmacist or pharmacy committed fraud or intentional misrepresentation described by Subsection (a), the health benefit plan issuer or pharmacy benefit manager must state the allegation in the final audit report required by Section 1369.264.(c)  After an audit is initiated, a pharmacist or pharmacy may resubmit a claim described by Subsection (a) if the deadline for submission of a claim under Section 843.337 or 1301.102 has not expired.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.261 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.261. Access to Previous Audit Reports; Uniform Audit Standards

Sec. 1369.261.  ACCESS TO PREVIOUS AUDIT REPORTS; UNIFORM AUDIT STANDARDS.  (a)  Except as provided by Subsection (b), a health benefit plan issuer or pharmacy benefit manager may have access to an audit report of a pharmacist or pharmacy only if the report was prepared in connection with an audit conducted by the health benefit plan issuer or pharmacy benefit manager.(b)  A health benefit plan issuer or pharmacy benefit manager may have access to audit reports other than the reports described by Subsection (a) if, after reviewing claims data, written or oral statements of pharmacy staff, wholesalers, or others, or other investigative information, including patient referrals, anonymous reports, or postings on Internet websites, the plan issuer or the pharmacy benefit manager suspects the audited pharmacist or pharmacy committed fraud or made an intentional misrepresentation related to the pharmacy business.(c)  An auditor must conduct an on-site audit or a desk audit of similarly situated pharmacists or pharmacies under the same audit standards.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.262 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.262. Compensation of Auditor

Sec. 1369.262.  COMPENSATION OF AUDITOR.  An individual performing an on-site audit or a desk audit may not directly or indirectly receive compensation based on a percentage of the amount recovered as a result of the audit.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.263 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.263. Conclusion of Audit; Summary; Preliminary Audit Report

Sec. 1369.263.  CONCLUSION OF AUDIT; SUMMARY; PRELIMINARY AUDIT REPORT.  (a)  At the conclusion of an on-site audit or a desk audit, the health benefit plan issuer or pharmacy benefit manager shall:(1)  provide to the pharmacist or pharmacy a summary of the audit findings; and(2)  allow the pharmacist or pharmacy to respond to questions and alleged discrepancies, if any, and comment on and clarify the findings.(b)  Not later than the 60th day after the date the audit is concluded, the health benefit plan issuer or pharmacy benefit manager shall send by a means that allows tracking of delivery to the pharmacist or pharmacy a preliminary audit report stating the results of the audit and a list identifying documentation, if any, required to resolve discrepancies, if any, found as a result of the audit.(c)  The pharmacist or pharmacy may, by providing documentation or otherwise, challenge a result or remedy a discrepancy stated in the preliminary audit report not later than the 30th day after the date the pharmacist or pharmacy receives the report.(d)  The pharmacist or pharmacy may request an extension to provide documentation supporting a challenge.  The request shall be reasonably granted.  A health benefit plan issuer or pharmacy benefit manager that grants an extension is not subject to the deadline to send the final audit report under Section 1369.264.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.264 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.264. Final Audit Report

Sec. 1369.264.  FINAL AUDIT REPORT.  Not later than the 120th day after the date the pharmacist or pharmacy receives a preliminary audit report under Section 1369.263, the health benefit plan issuer or pharmacy benefit manager shall send by a means that allows tracking of delivery to the pharmacist or pharmacy a final audit report that states:(1)  the audit results after review of the documentation submitted by the pharmacist or pharmacy in response to the preliminary audit report; and(2)  the audit results, including a description of all alleged discrepancies and explanations for and the amount of recoupments claimed after consideration of the pharmacist's or pharmacy's response to the preliminary audit report.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|
TX Ins Code § 1369.265 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle E - Benefits Payable Under Health Coverages|Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services|Subchapter F. Audits of Pharmacists and Pharmacies|Section 1369.265. Certain Audits Exempt From Deadlines

Sec. 1369.265.  CERTAIN AUDITS EXEMPT FROM DEADLINES.  A health benefit plan issuer or pharmacy benefit manager is not subject to the deadlines for sending a report under Sections 1369.263 and 1369.264 if, after reviewing claims data, written or oral statements of pharmacy staff, wholesalers, or others, or other investigative information, including patient referrals, anonymous reports, or postings on Internet websites, the plan issuer or pharmacy benefit manager suspects the audited pharmacist or pharmacy committed fraud or made an intentional misrepresentation related to the pharmacy business.|Added by Acts 2013, 83rd Leg., R.S., Ch. 915 (H.B. 1358), Sec. 1, eff. September 1, 2013.|