Self-Audit Series #12: Invoice Audits

PBMs have dramatically increased the number of invoice audits conducted and some pharmacies continue to be at risk for significant financial recoupments and contract terminations. It is not uncommon for invoice audit results to exceed six figures. To reduce the risk of your pharmacy having problems during a PBM invoice audit, consider performing a mock audit on your practice. The PBM is simply comparing the “ins” and “outs” of your pharmacy inventory for a specific period. If your “ins” are less than your “outs” for the PBM auditing, they conclude you have a shortage and will initiate recoupment. The “ins” are your acquisitions, or purchases, from wholesalers, manufacturers, trade shows or other pharmacies (note: there is no accounting for inventory on-hand). The “outs” are the claims that you billed to the PBM conducting the audit as well as any returns. The PBM already has the billed claims for the defined window, so when they initiate the invoice audit, they’re typically just in need of your purchasing history. Several PBMs, including OptumRx®, Elixir®, and Express Scripts® may even require the pharmacy to submit a full dispensing history for further reconciliation. Follow the tips below to reduce the risk of your pharmacy having problems during a PBM invoice audit.

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

PAAS Tips:

  • Create and maintain a list of all wholesalers from who you purchased prescription, over-the-counter (OTC) and supply items that are billed to third parties
  • Verify that wholesalers are licensed in your stateNational Association of Boards of Pharmacy (NABP)  Drug Distributor accredited, and can provide pedigrees in accordance with FDA Track and Trace Law
    • OptumRx requires network pharmacies source both prescription and OTC products from a supplier that is a licensed drug wholesaler in your state AND meets accreditation
    • Caremark and Express Scripts both require network pharmacies only purchase diabetic supplies from suppliers that are identified as “authorized distributors” by the manufacturers. Please refer to the July 2021 Newsline article, Life Scan Hires Law Firm to Pursue Pharmacies Purchasing from Unauthorized Distributors for manufacturer links to their authorized distributor lists.
  • Bulk purchases made outside the invoice audit date range are not always accepted by the PBM to account for additional inventory
    • CVS Caremark’s 2022 Provider Manual explicitly calls out bulk purchases of more than 30 days of inventory need to be preapproved, in writing [PAAS views the requirement as absurd and strongly opposes it]
  • Limit or eliminate the amount of inventory acquired from other pharmacies
    • If you must purchase inventory from another pharmacy, be aware of Drug Supply Chain Security Act (DSCSA) exceptions and keep good records of inventory acquisition, including proof of payment
  • Retain access to invoices and proof of payment for 10 years to coincide with Medicare Part D record retention requirements
  • Bill accurate NDC on all claims – all 11 digits are important
  • Bill accurate quantity on all claims – call PAAS National® (608) 873-1342 if unsure about billing unit or package size
  • Check your will-call bins to ensure that you are adhering to your Return to Stock (RTS) Policy, reverse any claims that are exceeding PBM limits
  • Verify that pharmacy management software has products marked as “active” only if you have physical product on the shelf to reduce data entry errors
  • Read the Self-Audit Series #12: Invoice Audit  Newsline article from January 2020 on how to perform a self-audit on invoices
  • See our Self-Audit Mindset document available on our portal for additional guidance

Common Claim Denials for Medicare Part B

In the PAAS National® August 2019 Newsline article, Medicare Part B/DMEPOS Audits – Who are All These Contractors?, we explained that Medicare and Medicaid use a number of audit contractors to perform medical review audits on pharmacies. The three main contractors PAAS sees carrying out these audits are: DME Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and Supplemental Medical Review Contractors (SMRCs).

Many of the denied claims are due to not meeting medical necessity, frequency limitations, lacking supporting medical records and even basic coding mistakes. See PAAS Tips for links on billing specific DMEPOS items and required documentation for Medicare Part B claims.

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

  • General reasons for claim denials on any audit:
    • Date of service and date of delivery do not match
    • Missing proof of refill request
    • Medical records are not signed by the physician
  • Glucose Meter Testing strips
    • Patient is testing outside guidelines and medical records do not support a valid reason why
    • No testing logs to prove patient is testing outside guidelines
    • Wrong modifier attached to claim based on insulin-dependent and non-insulin dependent
  • Immunosuppressive drugs
    • Not a covered transplant = must be kidney, heart, liver, bone marrow/stem cell, lung, intestinal and pancreas (limited situations)
    • Transplant was not performed in a Medicare approved facility
    • Missing transplant date and/or location
    • Patient was not enrolled in Medicare A at the time of transplant
  • Therapeutic Shoes
    • Missing medical records all together
    • Medical records do not support one or more of the qualifying conditions listed on the certifying statement
    • Missing in-person evaluation of the patient’s feet conducted by the supplier prior to ordering including measurements and deformities
    • Foot examination performed by the supplier does not contain an objective in-person assessment of the patient wearing the shoes/inserts

PAAS Tips:

Manipulating Quantity or Days’ Supply to Bypass Plan Limits Will Cost You

Plan limit rejections are intended to help control costs, provide clinical edits, and assist pharmacies in ensuring patient safety. When an initial claim adjudication is rejected for exceeding plan limits (e.g., Max Quantity Limit or Quantity vs Time Limit), pharmacies need to proceed with caution. An order entry technician that subsequently rebills for a different quantity [and same days’ supply] or the same quantity [and different days’ supply] than originally submitted, is asking for that prescription to be audited. PBM analytics assume the original adjudication was submitted and rejected [accurately] and when a subsequent claim [typically within seconds] has an altered quantity or days’ supply, it’s suspected that the manipulation was done [inappropriately] to get a paid claim. How should pharmacies proceed?

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

When rejections like these happen, pharmacies need to pay close attention to any messages given on how to resolve the rejection, including calling the PBM help desk for an override or getting a prior authorization started with the prescriber. The prescriber could also decide to change the dose or prescribe an alternative medication.

Some examples of the INCORRECT way to handle rejections that have led to audits and recoupments:

  1. Test strips, #350 strips, with directions to “use up to 9x daily as needed.” The pharmacy received a rejection stating the plan only covers up to 8x daily. The claim was reprocessed for #350 strips for an incorrect 44-day supply resulting in potential recoupment for bypassing the plan limit.
  2. Oxycontin 30 mg, #90 tablets, with directions to “take 1 tablet 3x daily.” Plan limit rejection received for “Maximum 2 tablets per day”. The pharmacy reduced the quantity to #60 tablets and billed an incorrect 30-day supply resulting in potential recoupment for bypassing the plan limit.

What happens if a prescriber refuses to obtain a prior authorization or change the prescription to a clinically appropriate dose? Can the claim be split-billed? PAAS National® recommends against split billing or processing a claim as cash to circumvent a plan limit or prior authorization requirement. A doctor who refuses to obtain a prior authorization or change the dose could be a red flag for diversion with controlled substances. Remember that most plan limits are put in place based on appropriate clinical use and bypassing them can lead to overdoses, diversion, and/or death. Pharmacists have a corresponding responsibility to ensure that prescriptions are for legitimate medical purposes, especially for controlled substances (21 CFR 1306.04(a)).

PAAS Tips:

  • Always bill for the accurate days’ supply based on the quantity and the directions given on the prescription
  • Educate all pharmacy staff to identify rejection messages, how to properly resolve them, and to never purposely input the incorrect days’ supply or quantity to get a paid claim
  • Obtaining a prior authorization can often resolve the problem for six months to a year
    • Alternatively, the prescriber could send a new prescription [or verbally authorize] for a clinically appropriate dose or change in medication
    • Prescribers that are unwilling to obtain prior authorization or to change the prescription to a clinically appropriate dose may be a red flag for diversion with controlled substances
  • You may need to call the PBM help desk for assistance processing a claim or obtaining a proper override
  • Any DUR verifications, especially if using “M0” (prescriber consulted) to override the DUR, should have supporting documentation on the prescription or within retrievable electronic records
    • Use a proper clinical note when speaking with the prescriber’s office or help desk which includes the date, name and title of who you spoke with, what was discussed, and pharmacy staff initials
  • Do not split bill rejected claims
    • Charging the patient cash often leads to complaints [from the patient to an employer or PBM] and can be considered non-compliance with the provider manual and lead to remediation, including potential network termination
    • If you have exhausted all plan options and the patient insists on paying cash for the full prescription, be sure that you document authorization from the patient that they desire to pay the full cost and will not seek reimbursement from the insurance. This may protect you from accusations of non-compliance
  • Don’t be afraid to enlist the patient’s help. Having them file a complaint with their insurance can help expediate the prior authorization approval process

Bill It Right: V-Go® Insulin Delivery Device and Rapid Acting Insulin Vials

The Valeritas V-Go® Insulin Delivery Device (V-Go®), a disposable insulin delivery device, can be challenging to bill properly. Filling an order for V-Go® requires two separate prescriptions – the V-Go® delivery device and the rapid-acting insulin to be used within the V-Go® system.

Each box of V-Go® contains 30 single-use devices, each to be used over a 24-hour period and subsequently disposed of. Therefore, a single box should be billed as “30 each” for a 30-day supply. Due to the device being single-use only, it does not meet the Medicare Part B DME requirement of ability for repeated use and therefore should be billed as part of a patient’s Medicare Part D plan. V-Go® is a basal-bolus insulin delivery device, meaning it is able to deliver both a continuous basal level of insulin over a 24-hour period in addition to bolus dosing for meals. It comes in three dosing selections based off the basal level of insulin the patient requires – 20 units/24 hours (V-Go® 20), 30 units/24 hours (V-Go® 30), and 40 units/24 hours (V-Go® 40) – plus a maximum of an additional 36 units to be used for bolus dosing, dosed in 2-unit increments. In addition, the manufacturer requires each V-Go® be filled to capacity and after 24 hours what insulin is left in the device must be disposed of. Due to the maximum amount of units each device can hold and the inability to salvage any leftover insulin in the V-Go® delivery system after 24 hours, it calls for the prescriber to meticulously determine which V-Go® device is most appropriate for the patient.

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

The second prescription to consider is the insulin to be used along with the V-Go® system. Both insulin lispro injection (Humalog® U-100) and insulin aspart injection (Novolog® 100 units/mL) have been tested and approved for use within V-Go® delivery devices. Note that concentrated insulins and insulin pens are not designed for use with the V-Go® delivery system. As previously stated, each of the three V-Go® dosing selections have different maximum insulin units the device can provide each day, and since the reservoir must be filled to its maximum capacity, that maximum number of units should be used in calculating the correct days’ supply. For example, 1 vial of insulin (1000 units) used in a V-Go® 20 device, divided by a maximum 56 units per day (1000/56), equates to a 17 days’ supply. The chart below depicts additional device and vial combinations:

V-Go® Device Max Insulin Units Delivered Per Day Estimated Days’ Supply
1 vial 2 vials 3 vials
V-Go® 20 56 units 17 35 53
V-Go® 30 66 units 15 30 45
V-Go® 40 76 units 13 26 3

When determining the proper amount of vials to dispense, follow the guidance provided in the Can You Bill It As 30 Days? and Diabetic Injectables FAQ documents, found on PAAS Member Portal located on the Tools and Aids page, to ensure proper billing practices in case of audit.

PAAS Tips:

  • Per package labeling, V-Go® is to be dispensed as one kit and is unable to be broken
  • If a patient reports either a V-Go® or EZ Fill device is missing or damaged, replacement items may be requested from a V-Go® Customer Care Representative at 1-866-881-1209
  • For additional information pertaining to V-Go® billing, see the February 2019 Newsline article, Bill It Right! V-Go® Insulin Delivery Device and Insulin Vials

Top Medications Flagged for Unauthorized Substitutions

PAAS National® analysts have repeatedly seen auditors targeting claims with potentially undocumented substitution issues. They hope to find inappropriate substitutions which may result in recoupment of the claim. To decrease the risk of these recoupments, and better understand where the issue stems, let’s start with a bit of background information.

Since 1938, when a company seeks authorization for a new (non-biologic) drug, they must compile enough evidence for the U.S. Food and Drug Administration (FDA) to determine if the product will be approved for sale in the United States—this packet of information is referred to as the New Drug Application (NDA). Generally, the drug with the NDA becomes the reference listed drug (RLD, or brand-name) product. The RLD is what other companies’ reference when seeking approval for their equivalent product (or generic) through the Abbreviated New Drug Application (ANDA). The ANDA must provide the FDA with evidence that the product is equivalent to the FDA-identified RLD and must show in vivo bioequivalence to the reference standard (RS) drug product. The FDA usually selects one RS and generally it is the RLD, but in some cases they are different.  If the FDA has enough evidence to establish equivalency, when the ANDA generic is approved, it will be given an “AB” rating. Each ANDA must list a single RLD to which it is being compared and if the FDA did not set the RLD, an ANDA applicant must ask the Office of Generic Drugs to designate one. When different RLDs are utilized for the same drug product of the same strength by different companies on their ANDA, it creates the need for a three-character Therapeutic Equivalency (TE) code (e.g., AB1, AB2, AB3, etc.). Only drug products with the same three-character TE code which are listed under the same active ingredient heading can be freely substituted for each other, plus the authorized generic, unless prohibited by state regulation. Be aware that authorized generics do not appear in the Orange Book and are not evaluated by the FDA for an equivalency rating because they are the same products as their RLD, or brand-name drug, however, they do not use the brand name.

If, at this time, the FDA considers a product to not be therapeutically equivalent, it will assign it a “B” rating. Claims at risk for recoupment include those where the prescription was issued for a specific RLD (brand-name) but filled with a non-matching TE code product or those filled with a B-rated product. The FDA Orange Book can be accessed online and may be utilized to confirm equivalency for non-biologic drug products to prevent these recoupments.

Anyone unfamiliar with the Orange Book can read the Preface which contains very detailed explanations of how to use the book as well as the meaning of each code. Included is an example of the three-character TE code system using nifedipine. Adalat® CC and Procardia XL® extended-release tablets are both listed under the same active ingredient (nifedipine) heading. Adalat® CC is designated AB1 and Procardia XL® AB2. ANDA generics approved with Adalat® CC listed as the RLD would receive an AB1 rating, and those approved with the RLD Procardia XL®, AB2. To substitute an AB1-coded generic nifedipine extended-release tablet for Procardia XL® without contacting the prescriber would be inappropriate and the claim could face recoupment if audited.

Based on the observations of PAAS analysts, the following table contains the most common products incorrectly substituted with non-AB rated products, and subsequently flagged upon audit:

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

Active Ingredient Heading Dosage Form Possible Equivalency Codes Most Commonly Flagged Medications due to Undocumented Substitution PAAS Newsline Articles with Additional Info
Albuterol HFA aerosol inhaler AB1, AB2, BX Proventil®, ProAir®, Ventolin®, non-equivalent generic albuterol June 2020 – First AB-Rated Generic for Proventil® Approved
Epinephrine Autoinjector AB, BX EpiPen®, non-equivalent generic epinephrine
Isotretinoin Capsule AB1, AB2 ClaravisTM, Amnesteem®, Myorisan®, ZenataneTM, Absorica®, non-equivalent generic isotretinoin May 2021 – iPLEDGE® Requirements and Isotretinoin Therapeutic Equivalence Products Reminder
Methylphenidate ER tablets & ER capsules AB, AB1, AB2, AB3, BX Concerta®, Methylin ER, Ritalin LA®, Metadate CD®, Aptensio XRTM, non-equivalent generic methylphenidate ER November 2020 – Best Practices for Methylphenidate ER Substitution

PAAS Tips:

Would Your Spravato® Documentation PAAS an Audit?

Spravato® is a Schedule III controlled substance intranasal spray used in conjunction with an oral antidepressant for treatment-resistant depression in adults. It is part of the Risk Evaluation and Mitigation Strategy (REMS) Program and can only be dispensed and administered to patients in a REMS certified healthcare setting due to the risks of sedation, misuse, and abuse. PAAS National® alerted members in a February 2021 Newsline article How to Avoid Spravato® Audit Recoupments that we have seen attempted audit recoupments for Spravato® due to the pharmacy being unable to provide record of shipment received and dispensing information (including patient name, dose, number of devices, and date dispensed) per REMS guidelines. PBMs currently auditing Spravato® prescriptions include Elixir, MedImpact, Humana and Pharmacy Data Management, Inc. (PDMI.)

PAAS Tips:

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

  • Pharmacies that dispense Spravato® must:
    • Become certified: Have an authorized representative complete the certification process and monitor compliance with the REMS Program
    • Have policies and procedures in place to verify that a healthcare setting is also certified in the REMS Program prior to dispensing Spravato®
    • Be sure to train pharmacy staff that Spravato® can only be dispensed to a certified healthcare setting
    • Maintain records for proof of pharmacy employee training and that policies and procedures are in place and being followed
    • Maintain records of all shipments of Spravato® received and dispensing information including patient name, dose, number of devices dispensed and the date of the dispensing
    • Ensure proper documentation of dispensing to a certified healthcare setting occurs:
      • Need the name, address, and phone number of the doctor’s office
      • Need the printed name, title, signature, and date of the representative receiving the order
      • Need patient name, dose, number of devices dispensed and the date of the dispensing
    • Maintain records of all deliveries of Spravato®
  • Spravato® is intended for the patient to administer under the supervision of a healthcare professional
  • See our November 2019 Newsline article, Spravato® – Watch the Billing!,  for proper billing information, including package size and billing units

Webinar: PBM FWA Trends and COVID-19 Vaccine Audit Risks

On November 18, 2021 PAAS National® hosted PBM FWA Trends and COVID-19 Vaccine Audit Risks webinar. PAAS Audit Assistance members have access to the recorded webinar, in addition to many other tools and resources on the PAAS Portal.

This webinar reviews:

  • PBM Fraud, Waste and Abuse (FWA) Trends
  • COVID-19 Vaccine Audit Risks
    • Documentation Requirements
    • Additional Doses for Immunocompromised
    • Booster Doses for qualified patients
    • Medicare at-home patients
  • Pandemic related PBM waivers/concessions

Don’t Jump the Gun: Refill Too Soon Recoupments

Pharmacies know the importance of billing accurate days’ supply on prescriptions; however, there may be circumstances that can make this challenging. Medications that only come in one size or an unbreakable package may exceed what the patient will use during the plan limit timeframe. Claims dispensed for a plan limit, but the true day’s supply is greater, are an easy target for refilling too soon.

Pharmacies must be diligent in monitoring refills for claims submitted for a plan limit but will last the patient longer. The PBM only sees the days’ supply submitted on the claim. Once a prescription is audited, the directions for use will reveal the true days’ supply.

These claims are an easy target for audit as the PBM already received the initial/rejected claim days’ supply (suspected as the true days’ supply) and a subsequent claim with a shortened days’ supply (to meet plan limits). Based on this information, the PBM will audit subsequent refill too soon occurrences with a high margin of success.

Examples of prescriptions that pharmacies may need to dispense over the plan limit

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

include insulin, inhalers, eye drops, topicals and diabetic test strips. Since many of these come in one size and are considered an unbreakable package, the pharmacy may be forced to submit as a plan limit.

Here is an example of a pharmacy putting claims at risk for refilling too soon:

  • Prescription for 1 box of insulin pens with instructions that would last 34 days
  • Pharmacy ran the claim for the plan max of 30 days
  • Pharmacy refilled the prescription 23 days later
  • PBM paid claim because the adjudicated claim indicated a 30 days’ supply
  • Percentage of use of the actual days’ supply was only 68%

As you can see, adjusting the days’ supply by 4 days (to meet the plan limit) put a claim in jeopardy of refilling too soon.

PAAS Tips:

  • Always submit claims with accurate days’ supply first, many PBMs now have built-in overrides in place for smallest package sizes
  • Use smallest package size available when days’ supply exceeds plan limit
  • See our Can You Bill It As 30 Days? under our Tools & Aids section of the PAAS Member Portal
  • Utilize our Days Supply Charts and have them easily accessible for data entry staff to assist with accurate calculations
  • Self-audit prescriptions by running internal audits on high-risk prescriptions for days’ supply and refill accuracy;  see our Self-Audit Series of articles in our archive on the PAAS Member Portal
  • Include notation on patient label to help notify patient and pharmacy staff of true days’ supply
  • Check with software vendor to see if additional days’ supply fields are available for internal tracking

Beware: Same Ingredients, Different FDA Indications

Ozempic® is an injectable diabetic medicine used to improve glycemic control in adults for type 2 diabetes management. Please see our May 2021 Newsline New Package Size Available for Ozempic® for reference on how to bill for Ozempic®. On June 4, 2021, the FDA approved a new drug treatment for chronic weight management called Wegovy™ which has the exact same ingredient – semaglutide.

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

Similarly, Victoza® is also used to improve glycemic control in patients 10 years and older for type 2 diabetes and is composed of an ingredient called liraglutide. Saxenda® also contains liraglutide but is used for chronic weight management. Pharmacies need to be aware that there is an audit risk if the prescriber is ordering for off-label use.

GLP-1 Receptor Agonist Analog Name FDA Indication Goal Dose
Ozempic® semaglutide Type 2 diabetes management 0.5 mg or 1 mg weekly
Wegovy™ semaglutide Chronic weight management 2.4 mg weekly
Victoza® liraglutide Type 2 diabetes management 1.2 mg or 1.8 mg daily
Saxenda® liraglutide Chronic weight management 3 mg daily

PAAS Tips:

  • Prescribers may try to help patients get around plan exclusions for weight loss medications by prescribing Ozempic® or Victoza® at higher doses
    • FDA approved medications being used off-label like this would likely not be covered under federal programs and are subject to audit recoupment
    • Claims paid at point-of-sale do not guarantee payment
  • If a prescription is written for the Analog name, pharmacies need to confirm the diagnosis to bill the correct medication
  • These products come in multiple strengths and package sizes which would also need to be confirmed
  • Medicare Part D and Medicaid may restrict coverage of medications if the prescribed use is not for a medically accepted indication

PBM Provider Manual Updates – What You Need to Know

Pharmacy Benefit Managers (PBMs) update their provider manuals on occasion (some more frequently than others) and although the changes are applicable to the practice of all pharmacies contracted with that PBM, it can be difficult to keep track of the method by which each PBM updates their manual and where to find it.

  • Caremark – Generally they mail out a paper, hardcopy of their provider manual to contracted pharmacies every other year, on even years, and amendments on odd years. An electronic copy can also be found at the bottom of the Document Library on the pharmacy provider website (log in required).
  • Express Scripts® updates their manual and posts the newest version online in the Pharmacist Resource Center (log in required) along with an itemized list of updates. Pharmacy staff can read the itemized list if they are looking for an efficient way to access and review the updates.
  • Humana – Their provider manual is publicly accessible via the Pharmacy Manuals and Forms page of their website, which affords all pharmacies quick and easy access to the relevant information.
  • OptumRx® updates their provider manual multiples times each year. The newest being Version 4.1 which was published at the being of October 2021. The provider manual for OptumRx® is publicly available under the Manuals and Guides sections of the Health Care Professionals website. However, OptumRx® does not provide a summary of changes or a quick reference guide. Below are several significant updates from recent versions of their provider manual.

    Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

    • Contracted pharmacies must provide language interpreter services in accordance with their state’s requirements or regulations.
    • Examples of “computer records” are now included under desktop and telephone audits and investigational reviews; these examples include electronic prescriptions (new and refill authorizations) as well as electronically stored clarifications or notes.
    • Over the course of 2021 several major additions have been made to the discrepancy code list:
      • 1P and 4B – Previously, claims billed with an invalid prescriber DEA number received these codes. Now, they will be utilized for invalid NPI number as well.
      • 2L – This discrepancy has been utilized when a script was missing documentation to validate the clinical appropriateness on a claim with possible clinical issues (gender/age/drug). Now, it will also be used for “possible high dose” claims without documentation supporting the appropriateness of the dose.
      • 3B – This will be utilized on claims with missing or invalid Risk Evaluation & Mitigation Strategies (REMS) documentation. For additional REMS information, refer to the June 2021 Newsline article Would Your REMS Prescription Pass an Audit?
      • 4Q – In states where prescriptions issued by mid-level practitioners require information regarding the supervising doctor, this code will be used if the supervisor’s information is missing.


Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

PAAS Tips:

  • It is important to stay up to date on the requirements of each PBM you are contracted with
  • Becoming familiar with a PBMs pharmacy provider manual can help the pharmacy prevent recoupment when audited and remain proactive by ensuring pharmacy policies and procedures are in line with PBM requirements
  • If your pharmacy receives a PBM notification regarding a policy change, please forward the notice to PAAS National® via fax (608) 873-4009 or email