Okla. Stat. tit. 59, § 59-356.2v2

records - Written report - Copy - Recoupment.

A. The entity conducting an audit of a pharmacy shall:

1. Identify and specifically describe the audit and appeal

procedures in the pharmacy contract. Prescription claim

documentation and record-keeping requirements shall not exceed the

requirements set forth by the Oklahoma Pharmacy Act or other

applicable state or federal laws or regulations;

2. Give the pharmacy written notice by certified letter to the

pharmacy and the pharmacy’s contracting agent, including

identification of specific prescription numbers and fill dates to be

audited, at least fourteen (14) calendar days prior to conducting

the audit, including, but not limited to, an on-site audit, a desk

audit, or a wholesale purchase audit, request for documentation

related to the dispensing of a prescription drug or any reimbursed

activity by a pharmacy provider; provided, however, that wholesale

purchase audits shall require a minimum of thirty (30) calendar

days’ written notice. For an on-site audit, the audit date shall be

the date the on-site audit occurs. For all other audit types, the

audit date shall be the date the pharmacy provides the documentation

requested in the audit notice. The pharmacy shall have the

opportunity to reschedule the audit no more than seven (7) calendar

days from the date designated on the original audit notification;

3. Not interfere with the delivery of pharmacist services to a

patient and shall utilize every reasonable effort to minimize

inconvenience and disruption to pharmacy operations during the audit

process;

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4. Conduct any audit involving clinical or professional

judgment by means of or in consultation with a licensed pharmacist;

5. Not consider as fraud any clerical or record-keeping error,

such as a typographical error, scrivener’s error or computer error,

including, but not limited to, a miscalculated day supply,

incorrectly billed prescription written date or prescription origin

code, and such errors shall not be subject to recoupment. The

pharmacy shall have the right to submit amended claims

electronically to correct clerical or record-keeping errors in lieu

of recoupment. To the extent that an audit results in the

identification of any clerical or record-keeping errors such as

typographical errors, scrivener’s errors or computer errors in a

required document or record, the pharmacy shall not be subject to

recoupment of funds by the pharmacy benefits manager unless the

pharmacy benefits manager can provide proof of intent to commit

fraud. A person shall not be subject to criminal penalties for

errors provided for in this paragraph without proof of intent to

commit fraud;

6. Permit a pharmacy to use the records of a hospital,

physician, or other authorized practitioner of the healing arts for

drugs or medicinal supplies written or transmitted by any means of

communication for purposes of validating the pharmacy record with

respect to orders or refills of a legend or narcotic drug;

7. Permit a pharmacy to use drug purchase records without

limitation of date or source to validate the dispensing of a

prescription drug or a controlled dangerous substance, provided the

drug purchase was done in accordance with state or federal law;

8. Not include the dispensing fee amount or the actual invoice

cost of the prescription dispensed in a finding of an audit

recoupment unless a prescription was not actually dispensed or a

physician denied authorization of a dispensing order;

9. Audit each pharmacy under identical standards, regularity

and parameters as other similarly situated pharmacies and all

pharmacies owned or managed by the pharmacy benefits manager

conducting or having conducted the audit;

10. Not exceed one (1) year from the date the claim was

submitted to or adjudicated by a managed care company, nonprofit
ian denied authorization of a dispensing order;

9. Audit each pharmacy under identical standards, regularity

and parameters as other similarly situated pharmacies and all

pharmacies owned or managed by the pharmacy benefits manager

conducting or having conducted the audit;

10. Not exceed one (1) year from the date the claim was

submitted to or adjudicated by a managed care company, nonprofit

hospital or medical service organization, insurance company, third-

party payor, pharmacy benefits manager, a health program

administered by a department of this state, or any entity that

represents the companies, groups, or departments for the period

covered by an audit;

11. Not schedule or initiate an audit during the first seven

(7) calendar days of any month unless otherwise consented to by the

pharmacy;

12. Disclose to any plan sponsor whose claims were included in

the audit any money recouped in the audit;

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13. Not require pharmacists to break open packaging labeled

“for single-patient-use only”. Packaging labeled “for single-

patient-use only” shall be deemed to be the smallest package size

available; and

14. Upon recoupment of funds from a pharmacy, refund first to

the patient the portion of the recovered funds that were originally

paid by the patient, provided such funds were part of the

recoupment.

B. 1. Any entity that conducts wholesale purchase review

during an audit of a pharmacist or pharmacy shall not require the

pharmacist or pharmacy to provide a full dispensing report.

Wholesaler invoice reviews shall be limited to verification of

purchase inventory specific to the pharmacy claims paid by the

health benefits plan or pharmacy benefits manager conducting the

audit without limitation to date or source of purchase.

2. Any entity conducting an audit shall not identify or label a

prescription claim as an audit discrepancy when:

a. the National Drug Code for the dispensed drug is in a

quantity that is a subunit or multiple of the drug

purchased by the pharmacist or pharmacy as supported

by a wholesale invoice,

b. the pharmacist or pharmacy dispensed the correct

quantity of the drug according to the prescription,

and

c. the drug dispensed by the pharmacist or pharmacy

shares all but the last two digits of the National

Drug Code of the drug reflected on the supplier

invoice.

3. An entity conducting an audit shall accept as evidence,

without limitation to date or source of purchase, subject to

validation, to support the validity of a pharmacy claim related to a

dispensed drug:

a. redacted copies of supplier invoices in the

pharmacist’s or pharmacy’s possession, or

b. invoices and any supporting documents from any

supplier as authorized by federal or state law to

transfer ownership of the drug acquired by the

pharmacist or pharmacy.

4. An entity conducting an audit shall provide, no later than

five (5) calendar days after the date of a request by the pharmacist

or pharmacy, all supporting documents the pharmacist’s or pharmacy’s

purchase suppliers provided to the health benefits plan issuer or

pharmacy benefits manager.

C. A pharmacy shall be allowed to provide the pharmacy’s

computerized patterned medical records or the records of a hospital,

physician, or other authorized practitioner of the healing arts for

drugs or medicinal supplies written or transmitted by any means of

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communication for purposes of supporting the pharmacy record with

respect to orders or refills of a legend or narcotic drug.

D. The entity conducting the audit shall not audit more than

fifty prescriptions, with specific date of service, per calendar

year. The annual limit to the number of prescription claims audited

shall be inclusive of all audits, including any prescription-related

documentation requests from the health insurer, pharmacy benefits
d with

respect to orders or refills of a legend or narcotic drug.

D. The entity conducting the audit shall not audit more than

fifty prescriptions, with specific date of service, per calendar

year. The annual limit to the number of prescription claims audited

shall be inclusive of all audits, including any prescription-related

documentation requests from the health insurer, pharmacy benefits

manager or any third-party company conducting audits on behalf of

any health insurer or pharmacy benefits manager during a calendar

year.

E. If paper copies of records are requested by the entity

conducting the audit, the entity shall pay twenty-five cents ($0.25)

per page to cover the costs incurred by the pharmacy. The entity

conducting the audit shall provide the pharmacy with accurate

instructions, including any required form for obtaining

reimbursement for the copied records.

F. The entity conducting the audit shall:

1. Deliver a preliminary audit findings report to the pharmacy

and the pharmacy’s contracting agent within forty-five (45) calendar

days of conducting the audit;

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

following receipt of the preliminary audit findings report in which

to produce documentation to address any discrepancy found during the

audit; provided, however, 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 ten

(10) calendar days after receipt of additional documentation

provided by the pharmacy, as provided for in Section 356.3 of this

title;

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 final disposition

of the audit findings, including the appeals process as provided for

in Section 356.3 of this title; and

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

G. Each entity conducting an audit shall provide a copy of the

final audit results, and a final audit report upon request, after

completion of any review process to the plan sponsor.

H. 1. The full amount of any recoupment on an audit shall be

refunded to the plan sponsor. Except as provided for in paragraph 2

of this subsection, a charge or assessment for an audit shall not be

based, directly or indirectly, on amounts recouped.

2. This subsection does not prevent the entity conducting the

audit from charging or assessing the responsible party, directly or

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indirectly, based on amounts recouped if both of the following

conditions are met:

a. the plan sponsor and the entity conducting the audit

have a contract that explicitly states the percentage

charge or assessment to the plan sponsor, and

b. a commission to an agent or employee of the entity

conducting the audit is not based, directly or

indirectly, on amounts recouped.

I. Unless superseded by state or federal law, auditors shall

only have access to previous audit reports on a particular pharmacy

conducted by the auditing entity for the same pharmacy benefits

manager, health plan or insurer. An auditing vendor contracting

with multiple pharmacy benefits managers or health insurance plans

shall not use audit reports or other information gained from an

audit on a pharmacy to conduct another audit for a different

pharmacy benefits manager or health insurance plan.

J. Sections A through I of this section shall not apply to any

audit initiated based on or that involves fraud, willful

misrepresentation, or abuse.

K. If the Attorney General, after notice and opportunity for

hearing, finds that the entity conducting the audit failed to follow
n

audit on a pharmacy to conduct another audit for a different

pharmacy benefits manager or health insurance plan.

J. Sections A through I of this section shall not apply to any

audit initiated based on or that involves fraud, willful

misrepresentation, or abuse.

K. If the Attorney General, after notice and opportunity for

hearing, finds that the entity conducting the audit failed to follow

any of the requirements pursuant to the Pharmacy Audit Integrity

Act, the audit shall be considered null and void. Any monies

recouped from a null and void audit shall be returned to the

affected pharmacy within fourteen (14) calendar days. Any violation

of this section by a pharmacy benefits manager or auditing entity

shall be deemed a violation of the Pharmacy Audit Integrity Act.