Oregon Statutes 735.542 – Pharmacy claims audits; requirements
An entity that audits claims or an independent third party that contracts with an entity to audit claims:
Terms Used In Oregon Statutes 735.542
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Fraud: Intentional deception resulting in injury to another.
(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 (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]
See note under 735.530.