community-based services — OHCA prohibited from utilizing certain audit methods — Development and refinement with DOH of audit methodology. A. As used in this section: 1. "Error rate" means the percentage of dollars of audited claims found to be billed in error; 2. "Extrapolation" means the methodology of estimating an unknown value by projecting, with a calculated precision, i.e., margin of error, the results of a probability sample to the universe from which the sample was drawn; 3. "Probability sample" means the standard statistical methodology in which a sample is selected based on the mathematical theory of probability; 4. "Sample" means a statistically valid number of claims obtained from the universe of claims audited or reviewed; and 5. "Universe" means all paid claims or types of paid claims audited or reviewed during a specified time frame. B. For claims payable to providers of Medicaid home and community-based services submitted on or after January 27, 2020, but not later than November 1, 2027, the Oklahoma Health Care Authority shall not use: 1. Extrapolation or any other statistical method for the auditing of such claims that can result in a determination that a provider is required to repay any amount paid to such provider in excess of the amount of the audited claim, regardless of the claims error rate; or 2. Statistical sampling to audit submitted claims in a manner that can result in a liability amount in excess of the total amount of claims used in a statistical sample. C. The use by the Oklahoma Health Care Authority of any methodology as described in subsection A of this section prior to the effective date of this act, and which was performed pursuant to the provisions of Oklahoma Administrative Code 317:30-3-2.1 with respect to an audit period beginning on or after January 27, 2020, through November 1, 2025, shall be deemed as invalid and any demand for payment made to a provider on the basis of such methodology shall be null and void. The Oklahoma Health Care Authority shall not have authority to make any demand for repayment from a provider with respect to an audit the effect of which has been nullified pursuant to the provisions of this subsection or to impose a financial penalty upon such provider with respect to any such audit. D. The Oklahoma Health Care Authority shall comply with the requirements of Section 249 of Title 56 of the Oklahoma Statutes with respect to the reporting of alleged fraud. E. The Oklahoma Health Care Authority and the Department of Human Services shall work in conjunction to develop and refine an audit methodology with respect to claims submitted for payment by providers in the Home and Community Based Waivers related programs. The agencies shall develop an information and training program so that affected providers and their authorized agents have an opportunity to become familiar with the audit standards and have a clear and consistent set of guidelines with respect to the claims submission process and any possible audit activity. The joint program shall be complete and ready for presentation to providers and their authorized agents not later than November 1, 2027.
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