Audit Prerequisites and Procedures Clause Samples

Audit Prerequisites and Procedures. A. An audit involves a review of one (1) month or more of data (not to exceed six (6) years), and addresses broad operational areas including claim pricing accuracy, concurrent eligibility, formulary compliance, logic utilized in claims processing and, when applicable, rebates and/or Financial Benefits. An audit may be initiated by contacting any individual on PBM’s account management team. B. Sponsor or Auditor will supply a written request to begin an audit, which shall include an explanation of the scope of the audit and a list of items necessary to perform the audit. PBM shall provide the requested data within ten (10) business days. C. Sponsor or Auditor may supply an audit questionnaire containing questions and requests for information and documentation concerning, without limitation: 1. AWP source for audit period. 2. Source and associated logic for determining Brand Drug and Generic Drug designation. 3. Mandatory generic logic, including the processing logic of each DAW 4. Information concerning the computation of any guaranteed discounts, logic surrounding such computations and any definitions necessary, in the opinion of Sponsor or Auditor, to clarify such logic and or computation. 5. Copy of PBM policies and procedures 6. Results of PBM’s most recent SAS-70 audit PBM will make available on a claim by claim basis all claims utilized along with definition designations for each claim utilized in the denominator and the numerator of the specified computation for each time period in question. PBM shall transmit the completed audit questionnaire, along with all requested claims and computations, within ten (10) business days.