The PBM audit appeal process, explained

How the process usually unfolds

Many PBM audits move through similar stages: an audit notice, a records submission or on-site visit, preliminary findings, a period in which the pharmacy can dispute those findings, and then final findings. Some PBMs offer a further level of appeal after final findings. The names and number of stages differ from one PBM to another, which is why the findings letter and your contract are the starting point rather than a general rule.

Steps to prepare an appeal

1. Find the deadline and the appeal method in the findings letter. Write down where, how and by when the appeal must be sent, and put the date on the calendar.
2. Make sure you have the claim-level detail behind each finding. If the letter shows only totals, ask the PBM in writing for the claim list it is based on.
3. Sort the findings into three groups: those you accept, those your records clearly dispute, and those that need more investigation.
4. For each disputed claim, gather the evidence: the prescription, any documented clarifications, signature or delivery records, and the purchase invoices for the product dispensed.
5. Check the calculations. Where a finding concerns quantities or inventory, compare purchases with dispensing at the NDC level, allowing for equivalent products, pack sizes and units of measure. Our guide to NDC reconciliation explains how.
6. Write the appeal claim by claim: the claim reference, the finding, why you dispute it, and which attached document supports your position. Keep the language factual and specific.
7. Submit the appeal by the required method, keep a complete copy and proof of delivery, and note when you should expect a response.

What makes an appeal easier to review

• One entry for each disputed claim, using the same claim references as the findings letter.
• Every statement tied to a specific attached document.
• A clear explanation, with invoices, wherever an equivalent product or a different pack size was purchased.
• Only the patient information needed to support the claims, sent through a secure method.
• A short summary listing the claims disputed and the claims accepted.

When to involve an attorney

Some matters go beyond documentation questions, for example when findings are disputed after the final appeal level or when the pharmacy’s network participation is at issue. State law or program rules may also affect the process, and a licensed attorney can tell you whether any apply to your situation. Pharma360 provides legal representation through licensed attorneys under a separately scoped engagement, while the consulting team continues working on the records. If a demand for repayment has already been issued, see our recoupment and overpayment dispute support.

Frequently asked questions