<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".04" citation="COMAR 31.10.47.04" title_num="31" subtitle_num="10" chapter_num="47" heading="Internal Appeal Procedures.">
  <paragraph num="A.">
    <text>Each PBM subject to this chapter shall establish written procedures to investigate and resolve disputes filed by a contracted pharmacy.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The internal appeal procedures established by the PBM shall:</text>
    <paragraph num="(1)">
      <text>Be in writing; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Contain administrative processes and safeguards designed to ensure and verify that the pricing was determined in accordance with the participating pharmacy contract and Maryland law, and that the contract provisions have not been applied in an arbitrary or capricious manner.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>The procedures established by the PBM may not require:</text>
    <paragraph num="(1)">
      <text>More than one appeal before filing a complaint with the Commissioner; or</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The payment of a fee to file an appeal.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>The internal appeal procedures established by the PBM shall be provided to the Commissioner on request.</text>
  </paragraph>
  <paragraph num="E.">
    <text>The internal procedures established by the PBM shall:</text>
    <paragraph num="(1)">
      <text>Provide written notice of the PBM’s decision no later than 90 days after receipt of the appeal or review;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Pay any money due within 30 days after the internal review is complete; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Provide a contracted pharmacy:</text>
      <paragraph num="(a)">
        <text>21 days to file an appeal after the contracted pharmacy is charged a direct or indirect remuneration fee; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A minimum of 180 days to request review of the reimbursement amount of a submitted claim.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>