Optum Rx has a strict non-retaliation policy which protects those reporting any adverse action as a result of a good faith report. Administrator actively investigates and refers, as appropriate, any FWA activity by Network Pharmacy Providers, associates, Members, vendors, contractors and/or other business entities.
Network Pharmacy Provider should initiate an investigation immediately, but no more than two (2) weeks from the date a potential compliance or fraud matter has been reported or identified. If, upon investigation, the Network Pharmacy Provider believes a potential misconduct has occurred, the Network Pharmacy Provider is required to report the alleged activity to the Administrator without fear of retaliation.
Network Pharmacy Providers may report any suspected or potential FWA to one of the following:
- National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC) - 877-7SAFERX (877-772-3379)
- Pharmacy Programs – 800-613-3591 or via email email@example.com
- Customer service number identified on the back of a Member’s ID card
- If a Network Pharmacy Provider suspects any fraud and/or abuse by a Member or Managed Care Organization (MCO), the Network Pharmacy Provider must report this to Administrator (OptumRx) and the applicable federal/state agency (e.g. Drug Enforcement Administration, Board of Pharmacy, etc.)
Note: In addition to the reporting requirements above, Network Pharmacy Providers must cooperate and assist any federal/ state agency charged with the duty of identifying, investigating, sanctioning or prosecuting suspected FWA. Network Pharmacy Providers must provide original and/or copies of any and all information as requested by any such federal/ state agency, allow access to premises, as well as provide records to any federal/state government unit or investigating agency, upon request (i.e. free-of-charge).
For additional information on FWA and general compliance, visit the Optum Rx Provider Manual at: professionals.optumrx.com/resources/manuals-guides/provider-manual.html