340B hospitals and health centers say they have a lot of questions about new requests from Express Scripts (ESI) to verify 340B drug reimbursement claims in 10 business days.
Hospital and health center covered entities report getting one or more email messages from the pharmacy benefit manager during the past week with lists of “claims submitted by your location that have been identified as 340B eligible.” Some entities report being asked about fewer than five claims. One reported being asked about roughly 1,300. The claims all appear to be related to drugs dispensed by in-house pharmacies only, not contract pharmacies, entities say.
The message says, “If you disagree that these claims are 340B eligible, please provide notice of such dispute within 10 business days of the date of this letter” including “evidence to support your position.”
“Express Scripts will review your dispute and the supporting evidence for accuracy,” the message continues. “If you have not heard from Express Scripts within 10 days of submitting your timely dispute notice and evidence, then Express Scripts has approved your dispute and will not consider these claims as 340B eligible. Failure to submit a dispute notice within 10 days will be considered validation of the 340B eligible status for the claims presented.”
“Your claim reimbursement is not affected by the claim’s status as 340B eligible,” the message says.
Entities say the inquiries raise a host of red flags, including:
- ESI did not explain why it wants or needs the information or what it will do with it once it has it.
- It did not say who identified the claims as 340B eligible or explain how.
- Other comparable 340B claims-verification requests ask only for a yes/no response, not for an answer plus supporting documentation.
- ESI did not say what evidence it will accept to support an entity’s answer.
- The 10-business-day deadline is short and overlaps with the Passover and Easter holidays, when many schools are on spring break and many families take vacations.
Some 340B entities and entity consultants said lists of claims they were asked to review had high percentages of claims for prescriptions that were never picked up by the patient at the pharmacy. These claims were reversed, and the drugs were returned to stock, entities and consultants said.
ESI and groups representing 340B entities are still at odds over the PBM’s now-year-old 340B claims identification requirement for covered entities and their contract pharmacies.
Effective March 1, 2021, ESI has required that, when a claim is determined post-adjudication to be 340B-eligible, that pharmacies resubmit the claim using a claims-transaction protocol called N1, with codes showing the claim was filled with 340B-purchased drugs.
Entities said when the requirement was rolled out that that they and their contract pharmacies were not equipped to use the N1 transaction. The National Council for Prescription Drug Programs, they pointed out, has cautioned against using the N1 unless all trading partners in the sequence are able to support its use. Groups asked ESI to withdraw the policy, but it remains in place.
An ESI spokesperson did not respond to an invitation yesterday to comment on entities’ concerns about the new 340B claims verification requests.
