ORS 735.542
Pharmacy claims audits
- requirements
(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)
May not conduct an audit of a claim more than 24 months after the date the claim was adjudicated by the entity;(3)
Must give at least 15 days’ advance written notice of an on-site audit to the pharmacy or corporate headquarters of the pharmacy;(4)
May not conduct an on-site audit during the first five days of any month without the pharmacy’s consent;(5)
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;(6)
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;(7)
May not conduct more than one on-site audit of a pharmacy in any 12-month period;(8)
Must audit each pharmacy under the same standards and parameters that the entity uses to audit other similarly situated pharmacies;(9)
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);(10)
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;(11)
May not recoup costs associated with:(a)
Clerical errors; or(b)
Other errors that do not result in financial harm to the entity or a consumer; and(12)
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]
Source:
Section 735.542 — Pharmacy claims audits; requirements, https://www.oregonlegislature.gov/bills_laws/ors/ors735.html.
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