58-29F-5. Audit terms.

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.

Source: SL 2013, ch 254, § 5.