Insurance Audit Assistance (PBM‑Initiated)
Overview
This service supports audits once initiated by a PBM or third party. Prevention tactics are addressed under Operations Management.
Outcomes
· Reduce chargebacks and contain exposure
· Clear, timely, and complete responses to audit requests
Typical deliverables
· Document gathering & reconciliation (RX, signatures, inventory, logs)
· Drafting responses and uploading to PBM portals within deadlines
· Appeals package for chargebacks with supporting documentation
· Status tracking and communication with payors/third parties
FAQs
What documentation do PBM auditors usually request first?
Expect prescription images, prescriber credentials, dispensing logs, signature logs/proofs of delivery, DAW documentation, inventory/compounding logs, and NDC/label verification aligned to the claim.
How fast do I need to respond, and what if I can’t meet the deadline?
Windows are often 10–30 days. Request extensions in writing before the deadline, confirm receipt, and document all communications.
What makes an effective appeal of audit chargebacks?
Be concise and evidence‑based: cite the contract/manual, attach missing/clarifying documents, and explain why the claim was payable.
How can I reduce audit risk going forward?
Tighten days’ supply and NDC controls, standardize transfer documentation, and audit signature/POD workflows. Prevention lives under Operations Management.
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