340B Duplicate Discount Prevention Review

Inspection template to reconcile Medicaid billing against 340B dispenses and identify potential duplicate discounts, carve-in/carve-out mismatches, and claim-level exceptions.

Review Setup and Scope

• Review period is defined and matches the claim extract date range
• Covered entity sites and contract pharmacies included in scope are listed
• Medicaid claim file and 340B dispense file were obtained for the same review period
• State Medicaid duplicate discount policy and carve-in/carve-out status were verified for the review period

Claim and Dispense Reconciliation

• Number of Medicaid claims reviewed
• Number of 340B dispenses reviewed
• Claims billed to Medicaid were matched to dispense records using patient, date of service, NDC, and prescription identifier where available
• Potential duplicate discount exceptions were identified and logged
• Claims with missing or conflicting identifiers were flagged for manual review

Carve-In / Carve-Out and Billing Controls

• Medicaid carve-in or carve-out status is consistently applied for the reviewed locations
• Claims excluded from 340B billing were not submitted as 340B-eligible Medicaid claims
• Managed care, fee-for-service, and other Medicaid payer types were separated according to policy
• Billing edits or claim exclusion logic prevented duplicate discount submission

Exception Review and Root Cause

• Number of potential duplicate discount exceptions
• Each exception has a documented root cause
• Exceptions were categorized as data issue, billing setup issue, pharmacy workflow issue, or policy issue
• High-risk or repeated exceptions were escalated to compliance or pharmacy leadership

Corrective Actions, Documentation, and Sign-Off

• Corrective actions were assigned for all unresolved exceptions
• Supporting documentation for the reconciliation is retained and retrievable
• Follow-up review date
• Inspector sign-off