Section 760 IAC 5-3-3 - Conduct of auditAuthority: IC 27-1-24.5-20
Affected: IC 25-26; IC 27-1-24.5-22
Sec. 3.
An auditor conducting an audit must comply with all of the following:
(1) The contract under which the audit is performed must provide a description of audit procedures that will be followed.(2) For an onsite audit conducted at a pharmacy's location, the auditor that conducts the audit must provide written notice to the pharmacy or pharmacist at least fourteen (14) calendar days before conducting the initial onsite audit for each audit cycle.(3) The auditor must not interfere with the delivery of pharmacist services to a patient, and must use every effort to minimize inconvenience and disruption to pharmacy operations during the audit. This subdivision does not prohibit audits during normal business hours of the pharmacy.(4) If the audit requires use of clinical or professional judgment, the audit must be conducted by or in consultation with an individual licensed as a pharmacist under IC 25-26.(5) The auditor must allow the use of written or otherwise transmitted hospital, physician, or other health practitioner records to validate a pharmacy record.(6) The auditor must perform the audit according to the same standards and parameters that the auditor uses to audit all other similarly situated pharmacies.(7) The period covered by the audit must not exceed twenty-four (24) months after the date on which a claim that is the subject of the audit was submitted to or adjudicated by the pharmacy benefit manager, unless a longer period is required under federal or state law. The pharmacy must be permitted to resubmit electronically any claims disputed by the audit. Audit procedures must provide for a period of at least thirty (30) calendar days during which the pharmacy may resubmit a disputed claim.(8) The auditor must not schedule an audit to begin during the first seven (7) calendar days of a month without the voluntary consent of the pharmacy. The consent may not be mandated by a contract or other means.(9) Payment to the auditor for conducting the audit must not be based on a percentage of the amount recovered as a result of the audit.(10) Within twenty-four (24) hours of receiving the notice of an audit, a pharmacy may reschedule the audit to a date not more than fourteen (14) calendar days after the date proposed by the auditor. However, if the auditor is unable to reschedule within the fourteen (14) calendar day period, the auditor must select and reschedule the audit for a date after the fourteen (14) calendar day period.(11) The auditor must allow a pharmacy or pharmacist to produce documentation to address a discrepancy found during the audit.Department of Insurance; 760 IAC 5-3-3; filed 2/23/2023, 9:48 a.m.: 20230322-IR-760220287FRA