20-3322. Audit procedures; interest prohibition

A. The following procedures apply to an audit conducted by an auditing entity:

1. When conducting an in-pharmacy audit an auditing entity shall:

(a) Give a pharmacy at least fourteen days' written notice.

(b) Not conduct an audit during the first five days of the month unless the pharmacy otherwise consents.

(c) Provide the pharmacy a list of items to be audited that provides for identification of prescription number or numbers or date range that the auditing entity is seeking to audit.

(d) When conducting an in-pharmacy or desktop audit, limit the audit to claims that may not exceed two years from the date that the claim was adjudicated by the pharmacy benefits manager.

2. An in-pharmacy audit or desktop audit that involves clinical or professional judgment shall be conducted by or in consultation with a pharmacist.

3. The pharmacy may use the records of a hospital, physician or other authorized practitioner to validate the pharmacy records. The validated records may be obtained via electronic methods, fax, phone or written prescription orders and do not have to be the original hard copy prescription order.

4. Each pharmacy shall be audited under the same standards and parameters as other similarly situated pharmacies in this state.

B. When conducting an in-pharmacy audit or desktop audit, an auditing entity shall comply with the following requirements:

1. The auditing entity shall base a finding of overpayment or underpayment on the actual overpayment or underpayment and not on a projection based on the number of patients served who have similar diagnoses or on the number of similar orders or refills for similar drugs, unless required by federal or state law.

2. The auditing entity may not recoup monies from the pharmacy for any clerical errors identified in an audit.

3. Any finding of an overpayment may not include the dispensing fee amount unless any of the following criteria are met:

(a) A prescription was not received by the patient or the patient's designee.

(b) The prescriber denied authorization.

(c) The prescription dispensed was a medication error by the pharmacy.

(d) The identified overpayment is based solely on an extra dispensing fee.

C. Interest may not accrue during the audit period.