How to respond to a PBM desk audit

Step by step: answering a desk audit request

1. Read the whole notice. Note the PBM or audit company, the claims selected, the documents requested, the required format and delivery method, and the response date. The deadline is set by the notice and your PBM contract, so take it from the notice rather than from memory of an earlier audit.
2. Put the deadline on the calendar and name one person to own the response. A single owner reduces the risk of duplicate, missing or mismatched pages. If you cannot meet the date, ask the auditor in writing, before it passes, whether more time is available, and keep their reply.
3. Build a working list of the selected claims. For each one, record the prescription number, fill date, drug and NDC, quantity and days’ supply as billed.
4. Pull the records for each claim: the prescription image or electronic prescription, any notes or clarifications, refill history, signature log or delivery record, and the purchase invoices that cover the product dispensed.
5. Check each document against the claim as billed. Confirm that the prescriber, drug, quantity and directions match, that copies are legible and complete, and that the invoices support the product and quantity dispensed.
6. Add a short, factual note only where a record needs context, for example when the product was purchased under a different NDC or pack size than the one billed.
7. Assemble the package claim by claim, in the order the auditor listed the claims, with each page labeled by its claim reference. Send it by the method the notice specifies.
8. Keep an exact copy of the package and proof of delivery. You may need both if findings are issued later.

Common reasons desk audit responses go wrong

• Missing pages, cut-off images or copies that are hard to read.
• Records that do not match the claim as billed, such as a different quantity, days’ supply or prescriber.
• Invoices that do not appear to cover the quantity dispensed, often because an equivalent product was bought under a different NDC or pack size and the connection was not explained.
• Unrelated documents mixed into the package, which make it harder for the reviewer to follow.
• A response sent late, or sent to the wrong place or in the wrong format.

Handle patient information carefully

Desk audit responses usually contain patient information, so send only what the request asks for, through the secure method the auditor specifies, and keep a record of what was shared. Do not enter patient information in the Pharma360 website form; once we are working together, we explain how records can be shared securely.

What happens after you respond

The PBM reviews the package and may issue findings for claims it considers unsupported. A findings letter normally explains how and by when the pharmacy can dispute them. If you receive findings, read our guide to the PBM audit appeal process. If the auditor is coming to the pharmacy instead, see how to prepare for a PBM on-site audit.

Frequently asked questions