58-29F-5. Audit terms.
397 words·~2 min read·
/sd/title-58/chapter-58-29/58-29f-5A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Unless otherwise prohibited by federal statutes or regulations, for any entity conducting a pharmacy audit the following audit items apply:
(1)The period covered by the audit may not exceed twenty-four months from the date that the claim was submitted to or adjudicated by the entity, unless a longer period is required under state or federal law;
(2)If an entity uses random sampling as a method for selecting a set of claims for examination, the sample size shall be appropriate for a statistically reliable sample. Notwithstanding any other provision, the auditing entity shall provide the pharmacy a masked list that provides a prescription number or date range that the auditing entity is seeking to audit;
(3)An on-site audit may not take place during the first five business days of the months of December and January unless the pharmacy consents;
(4)An auditor may not enter any portion of the pharmacy area where patient-specific information is available unless escorted, and to the extent possible shall remain out of sight and hearing range of the pharmacy patients;
(5)Any recoupment may not be deducted against future remittances until final completion of any appeals process and both parties have received the results of the final audit;
(6)A pharmacy benefits manager may not require information to be written on a prescription unless the information is required to be written on the prescription by state or federal law. Recoupment may be assessed for items not written on the prescription if:
(a)Additional information is required in the provider manual; or
(b)The information is required by the Food and Drug Administration; or
(c)The information is required by the drug manufacturer's product safety program; and
(d)The information in subsections (a), (b), or
(c)is not readily available for the auditor at the time of the audit;
(7)The auditing company or agent may not receive payment based on a percentage of the amount recovered. This section does not prevent the entity conducting the audit from charging or assessing the responsible party, directly or indirectly, based on amounts recouped if:
(a)The plan sponsor and the entity conducting the audit have a contract that explicitly states the percentage charge or assessment to the plan sponsor; and
(b)A commission to an agent or employee of the entity conducting the audit is not based, directly or indirectly, on amounts recouped.