Upon receipt of clean claim the carrier must: (1) pay the total amount of the claim in accordance with the contract, (2) deny the entire claim and notify the provider why the claim will not be paid, (3) audit the entire claim, pay 100% of contracted rate and notify the provider that claim is being audited, or (4) pay a portion of the claim and deny or audit the remainder, paying 100% of the audited portion. Carriers must pay prescription claims within 21 calendar days or 18 calendar days if filed electronically, after the claim is affirmatively adjudicated. Before seeking a refund for a payment previously made to a provider, a carrier must provide a provider with the opportunity to appeal the request for a refund, and may not seek to recover the refund until all of the preferred provider’s internal appeal rights have been exhausted. Providers have a 95-day deadline for to submit claim.

Link to Existing Law: Title 28 Part 1 Ch. 21 Subchapter T Rules 28 TAC §21.2807

While PBMs are not specifically mentioned, they are likely included in the broad definition of applicable entities.