{"data":{"id":"us-ok/okla.-stat.-tit.-59-59-356.3","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 59, § 59-356.3","heading":"Appeals process - Dismissal - Fraud or willful","body":"misrepresentation - Application of act.\n\nA. Each entity conducting an audit shall establish a written\n\nappeals process under which a pharmacy may appeal an unfavorable\n\npreliminary audit report and/or final audit report to the entity.\n\nB. Following an appeal, if the entity finds that an unfavorable\n\naudit report or any portion thereof is unsubstantiated, the entity\n\nshall dismiss the audit report or the unsubstantiated portion of the\n\naudit report without any further action.\n\nC. Any final audit report, following the final audit appeal\n\nperiod, with a finding of fraud or willful misrepresentation shall\n\nbe referred to the district attorney having proper jurisdiction or\n\nthe Attorney General for prosecution upon completion of the appeals\n\nprocess. If a finding of fraud or willful misrepresentation is\n\nreferred to a district attorney under this subsection, the auditing\n\nentity shall notify the Attorney General as to whom the referral was\n\nmade and the date the referral was made.\n\nD. For any audit initiated based on suspicion of fraud, willful\n\nmisrepresentation, or abuse, the auditing entity shall provide, in\n\nwriting, at the time of the audit, a clear and conspicuous\n\ndeclaration to the pharmacy being audited that the audit is being\n\nconducted under suspicion of fraud, willful misrepresentation, or\n\nabuse and a statement of facts that supports the reasonable\n\nsuspicion. The entity conducting an audit based on suspicion of\n\nfraud, willful misrepresentation, or abuse shall provide a copy of\n\nthe clear and conspicuous declaration required by this subsection to\n\nthe pharmacy’s contracting agent by certified mail within five (5)\n\nbusiness days of notifying the pharmacy of an audit pursuant to this\n\nsection.\n\nE. The entity conducting an audit based on suspicion of fraud,\n\nwillful misrepresentation, or abuse shall:\n\n1. Deliver a preliminary findings report to the pharmacy and\n\nthe pharmacy’s contracting agent within ninety (90) calendar days of\n\nnotification of the audit;\n\n2. Allow the pharmacy at least ninety (90) calendar days\n\nfollowing the receipt of the preliminary audit findings report in\n\nwhich to produce documentation to address any discrepancy found\n\nduring the audit. A pharmacy may request an extension, not to\n\nexceed 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 thirty\n\n(30) calendar days after receipt of additional documentation\n\nprovided by the pharmacy;\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 the final\n\ndisposition of the audit findings, including the appeals process\n\npursuant to this section;\n\n6. Not accrue interest during the audit and appeal period;\n\n7. Ensure that each preliminary audit findings report submitted\n\npursuant to this section includes:\n\na. specific prescription numbers, fill dates, drug names,\n\nand NDC numbers, and\n\nb. the date of receipt of documents from the pharmacy,\n\nthe pharmacy’s contracting agent, or any other source\n\nassociated with the audit;\n\n8. Ensure that each final audit findings report includes any\n\nadditional documentation that was submitted to the auditing entity;\n\n9. Provide the plan sponsor a copy of the final audit results\n\nwithin thirty (30) calendar days of the final disposition of the\n\naudit; and\n\n10. At the request of the plan sponsor, provide a copy of the\n\nfinal audit report within thirty (30) calendar days of the request.\n\nF. Any entity conducting an audit that is based on suspicion of\n\nfraud, willful misrepresentation, or abuse shall provide to the\n\nOffice of the Attorney General:\nof the final audit results\n\nwithin thirty (30) calendar days of the final disposition of the\n\naudit; and\n\n10. At the request of the plan sponsor, provide a copy of the\n\nfinal audit report within thirty (30) calendar days of the request.\n\nF. Any entity conducting an audit that is based on suspicion of\n\nfraud, willful misrepresentation, or abuse shall provide to the\n\nOffice of the Attorney General:\n\n1. Notice at least two (2) calendar days prior to beginning\n\nperformance of an audit pursuant to this section;\n\n2. A preliminary report within five (5) business days of\n\nproviding a copy of the preliminary report to the pharmacy and the\n\npharmacy’s contracting agent pursuant to this section. The auditing\n\nentity may request an extension from the Attorney General, not to\n\nexceed an additional ninety (90) calendar days; and\n\n3. A final report within ten (10) calendar days following the\n\nclosure of the final appeal period for an audit performed pursuant\n\nto this section.\n\na. The final report for the Office of the Attorney\n\nGeneral shall include the name of each plan sponsor\n\nwhose claims were included in the audit recover, the\n\namount of funds recouped on behalf of the plan, the\n\ndate the plan sponsor was notified of the recoupment,\n\nthe date the plan sponsor was paid any recoupment, and\n\nthe name and contact information for the\n\nrepresentative of the plan sponsor who was notified of\n\nthe recoupment at issue in an audit pursuant to this\n\nsection.\n\nb. The auditing entity may request an extension from the\n\nAttorney General, not to exceed an additional ten (10)\n\ncalendar days.\n\nG. The Attorney General, authorized employees, and examiners\n\nshall have access to any pharmacy benefits manager’s files and\n\nrecords that may relate to any audit including, but not limited to,\n\nan audit that is based on suspicion of fraud, willful\n\nmisrepresentation, or abuse.\n\nH. The Attorney General may levy a civil or administrative fine\n\nnot less than One Hundred Dollars ($100.00) and not greater than Ten\n\nThousand Dollars ($10,000.00) for each violation of this section and\n\nassess any other penalty or remedy authorized by law.","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":"79a0785472b24b6f3ed055ca5aadda49668925e4c6d252c11c01a348022f4f3f","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-59-59-356.2v2","next":"us-ok/okla.-stat.-tit.-59-59-356.4"},"notice":"GroundRules: Original legal text. Not legal advice."}