Consider a covered entity that carves out Medicaid for qualifying 340B patients. What should that covered entity do when it finds out that a patient’s insurance changes from or to Medicaid and that the patient had long been discharged and the drugs that were dispensed to the patient have been ordered and replenished in the 340B account?

The answer depends on what the Policies and Procedures document states. The covered entity can move the purchases to the appropriate non-340B account (this would require credit and bill) or place the dispenses in the accumulator as negative quantities for future capture and adjustment, or simply ignore the change in insurance if the discovery occurs X months after the discharge date.

This is an example why a TPA should have access to the Policies and Procedures manual of a Covered Entity. We at make sure that we have access to the manual and have this as a part of our implementation and ongoing checklist.