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ENGROSSED HOUSE
BILL NO. 3342 By: Williams of the House
and
Woods of the Senate
An Act relating to Medicaid audits; creating the
Oklahoma Medicaid Audit Bill of Rights Act; defining
terms; providing certain protections for health care
providers; providing for advance notice; providing
for specialty appropriate audit; limiting scope of
audits; directing for no allowance of extrapolation;
providing for appeals process; providing for
noncodification; providing for codification; and
providing an effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new section of law not to be
codified in the Oklahoma Statutes reads as follows:
This act shall be known and may be cited as the "Oklahoma
Medicaid Audit Bill of Rights Act".
SECTION 2. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 5029.10 of Title 63, unless
there is created a duplication in numbering, reads as follows:
As used in this act:
1. "Audit" means an investigation or review of a claim
submitted by a health care provider if the investigation or review:
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a. is conducted by an auditor, and
b. involves records, documents, or information other than
the filed claim;
2. "Auditor" means
a. an insurance company,
b. a third-party payor,
c. the Oklahoma Health Care Authority, or
d. an entity that represents a responsible party,
including a company or group that administers claims
services;
3. "Clerical or recordkeeping error" means a mistake in the
filed claim regarding a required document or record, including, but
not limited to:
a. a typographical error,
b. a scrivener's error, or
c. a computer error; and
4. "Health care provider" means a person who is licensed,
certified, or otherwise authorized by the laws of this state to
administer health care services to Medicaid patients.
SECTION 3. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 5029.11 of Title 63, unless
there is created a duplication in numbering, reads as follows:
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A. Notwithstanding any other law, when an audit is conducted by
an auditor, the audit shall be conducted according to the following
bill of rights:
1. An auditor conducting the initial audit shall give the
health care provider notice of the audit at least one (1) week
before conducting the initial audit for each audit cycle;
2. An audit that involves the application of clinical or
professional judgment shall be conducted by or in consultation with
a health care provider of the same specialty as the health care
provider being audited;
3. A clerical or recordkeeping error shall not:
a. constitute fraud, or
b. be subject to criminal penalties without proof of
intent to commit fraud.
A claim arising pursuant to paragraph 3 of this subsection may
be subject to recoupment;
4. A finding of an overpayment or underpayment of a filed claim
may be a projection based on the number of patients served by the
health care provider having a similar diagnosis.
Recoupment of claims pursuant to this paragraph shall be based
on the actual overpayment unless the projection for overpayment or
underpayment is part of a settlement by the health care provider;
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5. When an audit is for a specifically identified problem that
has been disclosed to the health care provider, the audit shall be
limited to a claim that is identified by a claim number;
6. For an audit other than that described in paragraph 5 of
this subsection, the audit shall be limited to the greater of:
a. fifty claims, or
b. twenty-five one-hundredths of one percent (0.25%) of
the number of claims billed by the health care
provider to the auditor in the previous calendar year;
7. If an audit reveals the necessity for a review of additional
claims, the audit shall be conducted by one of the following methods
at the discretion of the health care provider:
a. on-site,
b. electronically, or
c. by the same method as the initial audit;
8. Except for an audit initiated pursuant to paragraph 5 of
this subsection, an auditor shall not initiate an audit of a health
care provider more than two times in a calendar year;
9. A recoupment shall not be based on:
a. documentation requirements in addition to the
requirements for creating or maintaining documentation
prescribed by state law, rule, federal law or
regulation, or
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b. a requirement that a health care provider perform
professional duties prescribed by state law, rule,
federal law, or regulation;
10. Recoupment shall only occur following the correction of a
claim and shall be limited to amounts paid in excess of amounts
payable under the corrected claim.
An auditor may recoup the entire overpaid claim if payment is
issued for the corrected claim on the same date.
Following a notice of overpayment, a health care provider shall
have at least sixty (60) days to file a corrected claim;
11. Approval of a health care service, health care provider, or
patient eligibility upon adjudication of a claim shall not be
reversed unless the health care provider obtained the adjudication
by fraud or misrepresentation of claim elements;
12. Each health care provider shall be audited under the same
standards and parameters as other similarly situated health care
providers audited by the auditor;
13. A health care provider shall be allowed at least sixty (60)
days following receipt of the preliminary audit report in which to
produce documentation to address any discrepancy found during the
audit;
14. The period covered by an audit shall not exceed twenty-four
(24) months from the date the claim was submitted to or adjudicated
by an auditor;
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15. The preliminary audit report pursuant to paragraph 13 of
this subsection shall be delivered to a health care provider within
one hundred twenty (120) days after the conclusion of the audit.
A final audit report shall be delivered to the health care
provider within six (6) months after the receipt of the preliminary
audit report or receipt of the final appeal as provided for in this
subsection, whichever is later; and
16. Notwithstanding any other provision in this section, the
auditor conducting the audit shall not use the accounting practice
of extrapolation in calculating recoupments or penalties for audits.
B. A recoupment of any disputed funds shall only occur after
final internal disposition of the audit, including the appeals
process as described in subsection C of this section.
C. 1. An auditor that conducts an audit shall:
a. establish an appeals process under which a health care
provider may appeal an unfavorable preliminary audit
report to the auditor, and
b. provide a copy of the final audit report to the health
benefit plan sponsor after the completion of any
review process.
2. If following the appeal pursuant to subparagraph a of
paragraph 1 of this subsection the auditor finds that an unfavorable
audit report or any portion of the unfavorable audit report is
unsubstantiated, the auditor shall dismiss the audit report or the
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unsubstantiated portion of the audit report without any further
proceedings.
D. The total amount of any recoupment on an audit shall be
refunded to the party responsible for payment of the claim.
SECTION 4. This act shall become effective November 1, 2026.
Passed the House of Representatives the 9th day of March, 2026.
Presiding Officer of the House
of Representatives
Passed the Senate the ___ day of __________, 2026.
Presiding Officer of the Senate