PBMs allow a limited amount of time for a prescription to be picked up or delivered to a patient before the claim must be reversed and the medication placed back into the pharmacy’s stock inventory. These time limits are in place to help prevent a claim from being paid for a medication that was never actually received by a patient.
Unfortunately, there is no standard timeframe across the industry for a medication to be returned to stock, ranging anywhere from 10 calendar days to 15 business days. Pharmacies need to be aware of the individual PBMs’ timeframe or go with the shortest amount of time, 10 calendar days, to reverse and return unclaimed medications to stock.
PAAS National® regularly sees claims flagged for full recoupment when a prescription under audit has been dispensed after the allowed return to stock timeframe. These recoupments are difficult to appeal, so your best defense is to make sure you have a procedure in place to reverse claims not picked up within the PBM’s return to stock policy window. PAAS FWA/HIPAA members have access to an Unclaimed Prescription Reversal Log found in Appendix B of their policy and procedure manual to help with this task. Members should also review Section 4.1.1 Unclaimed Prescriptions of their policy and procedure manual and update their timeframe as needed.
- Review the Return to Stock chart on the PAAS Member Portal for the most current PBM policies
- Update your FWA/HIPAA Policy & Procedure Manual as needed and update all staff on any changes
- Run daily reports for claims not picked up within your pharmacy’s return to stock policy
- Check with your software vendor to see if your point-of-sale system can be configured to stop the sale of any claims outside your return to stock policy
- LTC claims and partial fills/completions are NOT exempt from return to stock policies
- For LTC claims, the return to stock date is calculated from the date the claim is billed, not the date the medication is physically filled
- Be aware that Risk Evaluation and Mitigation Strategies (REMS) products may have more stringent requirements for pick-up, review the June 2021 article, Would Your REMS Prescription Pass an Audit?
- If a patient requests a medication be left on the shelf beyond the return to stock window, reverse and rebill the claim to restart the countdown to return to stock
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