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

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

of this section are final.