Okla. Stat. tit. 59, § 59-356.3: Appeals process - Dismissal - Fraud or willful

misrepresentation - Application of act.

A. Each entity conducting an audit shall establish a written

appeals process under which a pharmacy may appeal an unfavorable

preliminary audit report and/or final audit report to the entity.

B. Following an appeal, if the entity finds that an unfavorable

audit report or any portion thereof is unsubstantiated, the entity

shall dismiss the audit report or the unsubstantiated portion of the

audit report without any further action.

C. Any final audit report, following the final audit appeal

period, with a finding of fraud or willful misrepresentation shall

be referred to the district attorney having proper jurisdiction or

the Attorney General for prosecution upon completion of the appeals

process. If a finding of fraud or willful misrepresentation is

referred to a district attorney under this subsection, the auditing

entity shall notify the Attorney General as to whom the referral was

made and the date the referral was made.

D. For any audit initiated based on suspicion of fraud, willful

misrepresentation, or abuse, the auditing entity shall provide, in

writing, at the time of the audit, a clear and conspicuous

declaration to the pharmacy being audited that the audit is being

conducted under suspicion of fraud, willful misrepresentation, or

abuse and a statement of facts that supports the reasonable

suspicion. The entity conducting an audit based on suspicion of

fraud, willful misrepresentation, or abuse shall provide a copy of

the clear and conspicuous declaration required by this subsection to

the pharmacy’s contracting agent by certified mail within five (5)

business days of notifying the pharmacy of an audit pursuant to this

section.

E. The entity conducting an audit based on suspicion of fraud,

willful misrepresentation, or abuse shall:

1. Deliver a preliminary findings report to the pharmacy and

the pharmacy’s contracting agent within ninety (90) calendar days of

notification of the audit;

2. Allow the pharmacy at least ninety (90) calendar days

following the receipt of the preliminary audit findings report in

which to produce documentation to address any discrepancy found

during the audit. A pharmacy may request an extension, not to

exceed an additional forty-five (45) calendar days;

3. Deliver a final audit findings report to the pharmacy and

the pharmacy’s contracting agent signed by the auditor within thirty

(30) calendar days after receipt of additional documentation

provided by the pharmacy;

4. Allow the pharmacy to reverse and resubmit claims

electronically within thirty (30) calendar days of receipt of the

final audit report in lieu of the auditing entity recouping

discrepant claim amounts from the pharmacy;

5. Not recoup any disputed funds until after the final

disposition of the audit findings, including the appeals process

pursuant to this section;

6. Not accrue interest during the audit and appeal period;

7. Ensure that each preliminary audit findings report submitted

pursuant to this section includes:

a. specific prescription numbers, fill dates, drug names,

and NDC numbers, and

b. the date of receipt of documents from the pharmacy,

the pharmacy’s contracting agent, or any other source

associated with the audit;

8. Ensure that each final audit findings report includes any

additional documentation that was submitted to the auditing entity;

9. Provide the plan sponsor a copy of the final audit results

within thirty (30) calendar days of the final disposition of the

audit; and

10. At the request of the plan sponsor, provide a copy of the

final audit report within thirty (30) calendar days of the request.

F. Any entity conducting an audit that is based on suspicion of

fraud, willful misrepresentation, or abuse shall provide to the

Office of the Attorney General:

of the final audit results

within thirty (30) calendar days of the final disposition of the

audit; and

10. At the request of the plan sponsor, provide a copy of the

final audit report within thirty (30) calendar days of the request.

F. Any entity conducting an audit that is based on suspicion of

fraud, willful misrepresentation, or abuse shall provide to the

Office of the Attorney General:

1. Notice at least two (2) calendar days prior to beginning

performance of an audit pursuant to this section;

2. A preliminary report within five (5) business days of

providing a copy of the preliminary report to the pharmacy and the

pharmacy’s contracting agent pursuant to this section. The auditing

entity may request an extension from the Attorney General, not to

exceed an additional ninety (90) calendar days; and

3. A final report within ten (10) calendar days following the

closure of the final appeal period for an audit performed pursuant

to this section.

a. The final report for the Office of the Attorney

General shall include the name of each plan sponsor

whose claims were included in the audit recover, the

amount of funds recouped on behalf of the plan, the

date the plan sponsor was notified of the recoupment,

the date the plan sponsor was paid any recoupment, and

the name and contact information for the

representative of the plan sponsor who was notified of

the recoupment at issue in an audit pursuant to this

section.

b. The auditing entity may request an extension from the

Attorney General, not to exceed an additional ten (10)

calendar days.

G. The Attorney General, authorized employees, and examiners

shall have access to any pharmacy benefits manager’s files and

records that may relate to any audit including, but not limited to,

an audit that is based on suspicion of fraud, willful

misrepresentation, or abuse.

H. The Attorney General may levy a civil or administrative fine

not less than One Hundred Dollars ($100.00) and not greater than Ten

Thousand Dollars ($10,000.00) for each violation of this section and

assess any other penalty or remedy authorized by law.