{"data":{"id":"us-ok/okla.-stat.-tit.-59-59-356.2v2","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 59, § 59-356.2v2","heading":"Pharmacy audit requirements - Computerized medical","body":"records - Written report - Copy - Recoupment.\n\nA. The entity conducting an audit of a pharmacy shall:\n\n1. Identify and specifically describe the audit and appeal\n\nprocedures in the pharmacy contract. Prescription claim\n\ndocumentation and record-keeping requirements shall not exceed the\n\nrequirements set forth by the Oklahoma Pharmacy Act or other\n\napplicable state or federal laws or regulations;\n\n2. Give the pharmacy written notice by certified letter to the\n\npharmacy and the pharmacy’s contracting agent, including\n\nidentification of specific prescription numbers and fill dates to be\n\naudited, at least fourteen (14) calendar days prior to conducting\n\nthe audit, including, but not limited to, an on-site audit, a desk\n\naudit, or a wholesale purchase audit, request for documentation\n\nrelated to the dispensing of a prescription drug or any reimbursed\n\nactivity by a pharmacy provider; provided, however, that wholesale\n\npurchase audits shall require a minimum of thirty (30) calendar\n\ndays’ written notice. For an on-site audit, the audit date shall be\n\nthe date the on-site audit occurs. For all other audit types, the\n\naudit date shall be the date the pharmacy provides the documentation\n\nrequested in the audit notice. The pharmacy shall have the\n\nopportunity to reschedule the audit no more than seven (7) calendar\n\ndays from the date designated on the original audit notification;\n\n3. Not interfere with the delivery of pharmacist services to a\n\npatient and shall utilize every reasonable effort to minimize\n\ninconvenience and disruption to pharmacy operations during the audit\n\nprocess;\n\n4. Conduct any audit involving clinical or professional\n\njudgment by means of or in consultation with a licensed pharmacist;\n\n5. Not consider as fraud any clerical or record-keeping error,\n\nsuch as a typographical error, scrivener’s error or computer error,\n\nincluding, but not limited to, a miscalculated day supply,\n\nincorrectly billed prescription written date or prescription origin\n\ncode, and such errors shall not be subject to recoupment. The\n\npharmacy shall have the right to submit amended claims\n\nelectronically to correct clerical or record-keeping errors in lieu\n\nof recoupment. To the extent that an audit results in the\n\nidentification of any clerical or record-keeping errors such as\n\ntypographical errors, scrivener’s errors or computer errors in a\n\nrequired document or record, the pharmacy shall not be subject to\n\nrecoupment of funds by the pharmacy benefits manager unless the\n\npharmacy benefits manager can provide proof of intent to commit\n\nfraud. A person shall not be subject to criminal penalties for\n\nerrors provided for in this paragraph without proof of intent to\n\ncommit fraud;\n\n6. Permit a pharmacy to use the records of a hospital,\n\nphysician, or other authorized practitioner of the healing arts for\n\ndrugs or medicinal supplies written or transmitted by any means of\n\ncommunication for purposes of validating the pharmacy record with\n\nrespect to orders or refills of a legend or narcotic drug;\n\n7. Permit a pharmacy to use drug purchase records without\n\nlimitation of date or source to validate the dispensing of a\n\nprescription drug or a controlled dangerous substance, provided the\n\ndrug purchase was done in accordance with state or federal law;\n\n8. Not include the dispensing fee amount or the actual invoice\n\ncost of the prescription dispensed in a finding of an audit\n\nrecoupment unless a prescription was not actually dispensed or a\n\nphysician denied authorization of a dispensing order;\n\n9. Audit each pharmacy under identical standards, regularity\n\nand parameters as other similarly situated pharmacies and all\n\npharmacies owned or managed by the pharmacy benefits manager\n\nconducting or having conducted the audit;\n\n10. Not exceed one (1) year from the date the claim was\n\nsubmitted to or adjudicated by a managed care company, nonprofit\nian denied authorization of a dispensing order;\n\n9. Audit each pharmacy under identical standards, regularity\n\nand parameters as other similarly situated pharmacies and all\n\npharmacies owned or managed by the pharmacy benefits manager\n\nconducting or having conducted the audit;\n\n10. Not exceed one (1) year from the date the claim was\n\nsubmitted to or adjudicated by a managed care company, nonprofit\n\nhospital or medical service organization, insurance company, third-\n\nparty payor, pharmacy benefits manager, a health program\n\nadministered by a department of this state, or any entity that\n\nrepresents the companies, groups, or departments for the period\n\ncovered by an audit;\n\n11. Not schedule or initiate an audit during the first seven\n\n(7) calendar days of any month unless otherwise consented to by the\n\npharmacy;\n\n12. Disclose to any plan sponsor whose claims were included in\n\nthe audit any money recouped in the audit;\n\n13. Not require pharmacists to break open packaging labeled\n\n“for single-patient-use only”. Packaging labeled “for single-\n\npatient-use only” shall be deemed to be the smallest package size\n\navailable; and\n\n14. Upon recoupment of funds from a pharmacy, refund first to\n\nthe patient the portion of the recovered funds that were originally\n\npaid by the patient, provided such funds were part of the\n\nrecoupment.\n\nB. 1. Any entity that conducts wholesale purchase review\n\nduring an audit of a pharmacist or pharmacy shall not require the\n\npharmacist or pharmacy to provide a full dispensing report.\n\nWholesaler invoice reviews shall be limited to verification of\n\npurchase inventory specific to the pharmacy claims paid by the\n\nhealth benefits plan or pharmacy benefits manager conducting the\n\naudit without limitation to date or source of purchase.\n\n2. Any entity conducting an audit shall not identify or label a\n\nprescription claim as an audit discrepancy when:\n\na. the National Drug Code for the dispensed drug is in a\n\nquantity that is a subunit or multiple of the drug\n\npurchased by the pharmacist or pharmacy as supported\n\nby a wholesale invoice,\n\nb. the pharmacist or pharmacy dispensed the correct\n\nquantity of the drug according to the prescription,\n\nand\n\nc. the drug dispensed by the pharmacist or pharmacy\n\nshares all but the last two digits of the National\n\nDrug Code of the drug reflected on the supplier\n\ninvoice.\n\n3. An entity conducting an audit shall accept as evidence,\n\nwithout limitation to date or source of purchase, subject to\n\nvalidation, to support the validity of a pharmacy claim related to a\n\ndispensed drug:\n\na. redacted copies of supplier invoices in the\n\npharmacist’s or pharmacy’s possession, or\n\nb. invoices and any supporting documents from any\n\nsupplier as authorized by federal or state law to\n\ntransfer ownership of the drug acquired by the\n\npharmacist or pharmacy.\n\n4. An entity conducting an audit shall provide, no later than\n\nfive (5) calendar days after the date of a request by the pharmacist\n\nor pharmacy, all supporting documents the pharmacist’s or pharmacy’s\n\npurchase suppliers provided to the health benefits plan issuer or\n\npharmacy benefits manager.\n\nC. A pharmacy shall be allowed to provide the pharmacy’s\n\ncomputerized patterned medical records or the records of a hospital,\n\nphysician, or other authorized practitioner of the healing arts for\n\ndrugs or medicinal supplies written or transmitted by any means of\n\ncommunication for purposes of supporting the pharmacy record with\n\nrespect to orders or refills of a legend or narcotic drug.\n\nD. The entity conducting the audit shall not audit more than\n\nfifty prescriptions, with specific date of service, per calendar\n\nyear. The annual limit to the number of prescription claims audited\n\nshall be inclusive of all audits, including any prescription-related\n\ndocumentation requests from the health insurer, pharmacy benefits\nd with\n\nrespect to orders or refills of a legend or narcotic drug.\n\nD. The entity conducting the audit shall not audit more than\n\nfifty prescriptions, with specific date of service, per calendar\n\nyear. The annual limit to the number of prescription claims audited\n\nshall be inclusive of all audits, including any prescription-related\n\ndocumentation requests from the health insurer, pharmacy benefits\n\nmanager or any third-party company conducting audits on behalf of\n\nany health insurer or pharmacy benefits manager during a calendar\n\nyear.\n\nE. If paper copies of records are requested by the entity\n\nconducting the audit, the entity shall pay twenty-five cents ($0.25)\n\nper page to cover the costs incurred by the pharmacy. The entity\n\nconducting the audit shall provide the pharmacy with accurate\n\ninstructions, including any required form for obtaining\n\nreimbursement for the copied records.\n\nF. The entity conducting the audit shall:\n\n1. Deliver a preliminary audit findings report to the pharmacy\n\nand the pharmacy’s contracting agent within forty-five (45) calendar\n\ndays of conducting the audit;\n\n2. Allow the pharmacy at least ninety (90) calendar days\n\nfollowing receipt of the preliminary audit findings report in which\n\nto produce documentation to address any discrepancy found during the\n\naudit; provided, however, a pharmacy may request an extension, not\n\nto exceed an additional forty-five (45) calendar days;\n\n3. Deliver a final audit findings report to the pharmacy and\n\nthe pharmacy’s contracting agent signed by the auditor within ten\n\n(10) calendar days after receipt of additional documentation\n\nprovided by the pharmacy, as provided for in Section 356.3 of this\n\ntitle;\n\n4. Allow the pharmacy to reverse and resubmit claims\n\nelectronically within thirty (30) calendar days of receipt of the\n\nfinal audit report in lieu of the auditing entity recouping\n\ndiscrepant claim amounts from the pharmacy;\n\n5. Not recoup any disputed funds until after final disposition\n\nof the audit findings, including the appeals process as provided for\n\nin Section 356.3 of this title; and\n\n6. Not accrue interest during the audit and appeal period.\n\nG. Each entity conducting an audit shall provide a copy of the\n\nfinal audit results, and a final audit report upon request, after\n\ncompletion of any review process to the plan sponsor.\n\nH. 1. The full amount of any recoupment on an audit shall be\n\nrefunded to the plan sponsor. Except as provided for in paragraph 2\n\nof this subsection, a charge or assessment for an audit shall not be\n\nbased, directly or indirectly, on amounts recouped.\n\n2. This subsection does not prevent the entity conducting the\n\naudit from charging or assessing the responsible party, directly or\n\nindirectly, based on amounts recouped if both of the following\n\nconditions are met:\n\na. the plan sponsor and the entity conducting the audit\n\nhave a contract that explicitly states the percentage\n\ncharge or assessment to the plan sponsor, and\n\nb. a commission to an agent or employee of the entity\n\nconducting the audit is not based, directly or\n\nindirectly, on amounts recouped.\n\nI. Unless superseded by state or federal law, auditors shall\n\nonly have access to previous audit reports on a particular pharmacy\n\nconducted by the auditing entity for the same pharmacy benefits\n\nmanager, health plan or insurer. An auditing vendor contracting\n\nwith multiple pharmacy benefits managers or health insurance plans\n\nshall not use audit reports or other information gained from an\n\naudit on a pharmacy to conduct another audit for a different\n\npharmacy benefits manager or health insurance plan.\n\nJ. Sections A through I of this section shall not apply to any\n\naudit initiated based on or that involves fraud, willful\n\nmisrepresentation, or abuse.\n\nK. If the Attorney General, after notice and opportunity for\n\nhearing, finds that the entity conducting the audit failed to follow\nn\n\naudit on a pharmacy to conduct another audit for a different\n\npharmacy benefits manager or health insurance plan.\n\nJ. Sections A through I of this section shall not apply to any\n\naudit initiated based on or that involves fraud, willful\n\nmisrepresentation, or abuse.\n\nK. If the Attorney General, after notice and opportunity for\n\nhearing, finds that the entity conducting the audit failed to follow\n\nany of the requirements pursuant to the Pharmacy Audit Integrity\n\nAct, the audit shall be considered null and void. Any monies\n\nrecouped from a null and void audit shall be returned to the\n\naffected pharmacy within fourteen (14) calendar days. Any violation\n\nof this section by a pharmacy benefits manager or auditing entity\n\nshall be deemed a violation of the Pharmacy Audit Integrity Act.","path":["OK Code","Title 59"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os59.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"d49a8fa248744391fe5b503f38dccd9f76aea100f9f5525141f0499ac4579ad4","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-59-59-356.2v1","next":"us-ok/okla.-stat.-tit.-59-59-356.3"},"notice":"GroundRules: Original legal text. Not legal advice."}