Texas Insurance Code 1369.260 – Clerical or Recordkeeping Error; Fraud Allegation
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(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 § 1369.264.
Terms Used In Texas Insurance Code 1369.260
- Allegation: something that someone says happened.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Fraud: Intentional deception resulting in injury to another.
(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 § 843.337 or 1301.102 has not expired.