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: 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. Added by Laws 2008, c. 137, § 4, eff. Nov. 1, 2008. Amended by Laws 2011, c. 375, § 2, eff. Nov. 1, 2011; Laws 2021, c. 409, § 2, emerg. eff. May 4, 2021; Laws 2024, c. 332, § 3, emerg. eff. May 22, 2024;
‹ Prev All Oklahoma sections Next ›
Lexace provides legal information, not legal advice, and no attorney–client relationship is created. Statute text is provided for general information and may not reflect the most recent amendments; verify against the official state code.