Oregon Alternative Insurance
ORS 735.542
Pharmacy claims audits; requirements

An entity that audits claims or an independent third party that contracts with an entity to audit claims:


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;


May not conduct an audit of a claim more than 24 months after the date the claim was adjudicated by the entity;


Must give at least 15 days’ advance written notice of an on-site audit to the pharmacy or corporate headquarters of the pharmacy;


May not conduct an on-site audit during the first five days of any month without the pharmacy’s consent;


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;


May not conduct an on-site audit of more than 250 unique prescriptions of a pharmacy in any 12-month period except in cases of alleged fraud;


May not conduct more than one on-site audit of a pharmacy in any 12-month period;


Must audit each pharmacy under the same standards and parameters that the entity uses to audit other similarly situated pharmacies;


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 735.550 (Pharmacy claims audits) (3);


May not include dispensing fees or interest in the amount of any overpayment assessed on a claim unless the overpaid claim was for a prescription that was not filled correctly;


May not recoup costs associated with:


Clerical errors; or


Other errors that do not result in financial harm to the entity or a consumer; and


May not charge a pharmacy for a denied or disputed claim until the audit and the appeals procedure established under subsection (1) of this section are final. [2013 c.570 §5]
Note: See second note under 735.530 (Definitions for ORS 735.530 to 735.552).
Last accessed
May. 15, 2020