Audit and Appeal Due Dates: Stay Ahead of the Clock with These Essential Tips

Step 1: Audit Notice or Audit Results Received

• Dedicate a specific area for audit documents and inform pharmacy staff of what to do when audit notices are received
• Send your audit notice or audit results to PAAS as soon as you receive them
  • Utilize the PAAS Audit Activity Tracker you receive after submitting your audit notice or you can find it on our website under Proactive Tips
• Discuss with your PAAS analyst the appropriate documents needed for response
• Contact an auditor/PBM as soon as possible if you feel an extension may be needed
• Set calendar reminders for audit and appeal due dates

Step 2: Prepare your Documents

• Gather documents and organize in order of audit request
• Always number your pages for easier reference for you, your PAAS analyst, and the auditor
• When signature logs are requested on a separate list, keep those separate in your documents

Prescription Documents

• While many audits request multiple dates of fill, only one prescription hardcopy is necessary for each Rx#
• When printing electronic images of prescriptions, be sure to include any electronic clinical notations in your system for auditor to view
• Reminder all clinical notes should include:
  • Date
  • Name and title of agent you spoke with
  • Specific information that was provided
  • Initials of pharmacy employee that made the call
• Include any supporting documentation for DUR or SCC overrides
• When backtags or labels are requested, these can be added to the same page as the prescription
• Be sure backtags or labels do not cover any prescription elements
• Keep backtags or labels in same orientation as prescription
• Unless otherwise indicated, redact any pricing information

Signature/Delivery Requests

• Always confirm if audit is requesting signature/delivery logs
• Signature/delivery logs must include:
  • Rx number
  • Date of fill (or fill number)
  • Date dispensed
  • Patient/patient representative signature
• Redact any PHI not on audit request

Proof of Copay Collection

• Proof of copay collection is only needed when an audit specifically requests
• Point-of-Sale transactions, register receipts, or A/R account invoices showing how payment was made may be necessary for responses
• When secondary payors are involved, be sure to include claims data

Step 3: Submitting your Audit

• Audit requests provide specific instructions on how to submit your documents
• While faxing is typically an option, sending large audits this route is generally not advisable
• Sending via secure email or uploading to a portal are the best recommendations

Step 4: Audit Outcome

• Keep eyes open for audit results and inform staff of what to do when results are received
• Set calendar reminder to follow up on audit status when results are not received on a timely basis
• Remember, checking on your audit results will not change their outcome and may prevent you from missing an appeal deadline

Audit Results and Appeal

• Audit appeals are individualized for each PBM and discrepancy
• Review results closely for appeal deadlines as these vary per PBM
• Involve your PAAS analyst right away as appeal documentation may take additional time and effort to obtain
• Sending in your appeal documentation for your analyst review can be very helpful to identify any missing or incorrect information

PAAS Tips:

• Send your audit notice or audit results to PAAS right away
• Follow the PAAS National^® guidance for Getting Help with an Audit
• Submit audit notice, results or documents for review by uploading to our portal, faxing or emailing
• When sending electronically, be sure to send as one aggregated file with numbered pages
• If you send multiple attachments via fax or email, be sure each attachment is clearly labeled
• Consult our Call Center if you need assistance with submitting your documents
• Keep your PAAS analyst engaged on any updates or additional requests for your audit
• Consider training additional staff to assist with your audits as a back up