{"data":{"id":"us-wa/rcw-48.200.220","jurisdiction":"us-wa","citation":"RCW 48.200.220","heading":"Auditing of claims—Requirements—Prohibited practices.","body":"An entity that audits claims or an independent third party that contracts with an entity to audit claims:\n(1) Must establish, in writing, a procedure for a pharmacy to appeal the entity's findings with respect to a claim and must provide a pharmacy with a notice regarding the procedure, in writing or electronically, prior to conducting an audit of the pharmacy's claims;\n(2) May not conduct an audit of a claim more than twenty-four months after the date the claim was adjudicated by the entity;\n(3) Must give at least fifteen days' advance written notice of an on-site audit to the pharmacy or corporate headquarters of the pharmacy;\n(4) May not conduct an on-site audit during the first five days of any month without the pharmacy's consent;\n(5) Must conduct the audit in consultation with a pharmacist who is licensed by this or another state if the audit involves clinical or professional judgment;\n(6) May not conduct an on-site audit of more than two hundred fifty unique prescriptions of a pharmacy in any twelve-month period except in cases of alleged fraud;\n(7) May not conduct more than one on-site audit of a pharmacy in any twelve-month period;\n(8) Must audit each pharmacy under the same standards and parameters that the entity uses to audit other similarly situated pharmacies;\n(9) Must pay any outstanding claims of a pharmacy no more than forty-five days after the earlier of the date all appeals are concluded or the date a final report is issued under RCW 48.200.260(3);\n(10) May not include dispensing fees or interest in the amount of any overpayment assessed on a claim unless the overpaid claim was for a prescription that was not filled correctly;\n(11) May not recoup costs associated with:\n(a) Clerical errors; or\n(b) Other errors that do not result in financial harm to the entity or a consumer; and\n(12) May not charge a pharmacy for a denied or disputed claim until the audit and the appeals procedure established under subsection (1) of this section are final.","path":["Title 48","Chapter 48.200"],"source_url":"https://app.leg.wa.gov/rcw/default.aspx?cite=48.200.220","current_through":"July 15, 2026","vintage":"","retrieved_at":"2026-09-06T03:19:23Z","sha256":"26c8387ebec7e3edca468e4207039dafc998fef2e31d59c65009908bc7261393","source_id":"us-wa","stale":false,"prev":"us-wa/rcw-48.200.210","next":"us-wa/rcw-48.200.230"},"notice":"GroundRules: Original legal text. Not legal advice."}