Oregon Revised Statutes Chapter 735 § 735.542 — Pharmacy claims audits; requirements

Pharmacy claims audits; requirements. An entity that audits claims or an independent third party that contracts with an entity to audit claims: (1) Must establish, in writing, a procedure for a pharmacy to appeal the entity’s findings with respect to a claim and must provide a pharmacy with a notice regarding the procedure, in writing or electronically, prior to conducting an audit of the pharmacy’s claims; (2) Must submit requests for records from a pharmacy for the purpose of an audit by: (a) Electronic mail; and (b) Facsimile or certified mail; (3) May not conduct an audit of a claim more than 12 months after the date the claim was adjudicated by the entity; (4) Must give at least 15 days’ advance written notice of an on-site audit to the pharmacy or corporate headquarters of the pharmacy by electronic mail; (5) May not conduct an on-site audit during the first five days of any month without the pharmacy’s consent; (6) Must conduct the audit in consultation with a pharmacist who is licensed by this or another state if the audit involves clinical or professional judgment; (7)(a) May not audit, in any 12-month period, more than: (A) 250 unique prescriptions during an on-site audit; or (B) 250 unique prescriptions through a remote audit. (b) The limits on the number of drugs that may be audited described in paragraph (a) of this subsection do not include an audit conducted by a pharmacy benefit manager resulting from a reasonable suspicion by the pharmacy benefit manager of fraud, waste or abuse supported by preliminary evidence that the pharmacy benefit manager produces for the pharmacy. (8) May not conduct more than one on-site audit of a pharmacy in any 12-month period; (9) Must give a pharmacy at least 30 days to respond to an audit; (10) Must audit each pharmacy under the same standards and parameters that the entity uses to audit other similarly situated pharmacies; (11) Must pay any outstanding claims of a pharmacy no more than 45 days after the earlier of the date all appeals are concluded or the date a final report is issued under ORS