reglab/housing_qa huggingface dataset:
63 OK Stat § 63-5030.2 (2021)
2021 Oklahoma Statutes|Title 63. Public Health and Safety|§63-5030.2. Definitions.

|As used in Sections 1 through 5 of this act: |1. “Compendia” means the “American Hospital Formulary Services Drug Information”, “U.S. Pharmacopoeia Drug Information”, peer-reviewed medical literature, other information provided by individuals involved in health care, and information as needed by the Medicaid Drug Utilization Review Board;2. “Criteria” means those explicit and predetermined elements that are used to assess or measure drug use on an ongoing basis to determine if the use is appropriate, medically necessary, and not likely to result in adverse medical outcomes;3. “Authority” means the Oklahoma Health Care Authority;4. “Drug-disease contraindication” means the possibility that the therapeutic effect of a drug would be adversely altered by the presence of another disease or condition;5. “Drug interactions” means the possibility that two or more drugs taken by a patient may lead to clinically significant toxicity that is uncharacteristic of any one of the drugs present or that the taking of which leads to interference with the effectiveness of one or any of the drugs;6. “Drug to drug interaction” means a clinically significant adverse medical effect that results from the use of two or more drugs together;7. “Drug Utilization Review” or “DUR” means both retrospective and prospective drug utilization review designed to educate physicians and pharmacists and thereby ensure that prescriptions are appropriate, medically necessary and not likely to have adverse medical results;8. “Overutilization” or “underutilization” means the use of a drug in such quantities that the desired therapeutic goal is not achieved;9. “Prospective drug utilization review” means the part of a drug utilization review program that occurs before a drug is dispensed, and that is designed to screen, based on explicit and predetermined criteria and standards, for potential drug therapy problems, including, but not limited to:a.therapeutic duplication,b.drug-disease contraindications,c.incorrect drug dosage or duration of drug treatment,d.drug allergy interactions, ande.clinical abuse or misuse; and10. “Retrospective drug utilization review” means the part of the drug utilization review program that assesses or measures drug use based on an historical review of drug use data against predetermined and explicit criteria and standards on an ongoing basis with professional input. Retrospective drug utilization review includes the periodic examination of Medicaid drug pharmacy claims data and other information sources to identify the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care:a.among physicians, pharmacists, and patients, orb.associated with specific drugs.Added by Laws 1999, c. 201, § 2, eff. July 1, 1999.
63 OK Stat § 63-5030.3 (2021)
2021 Oklahoma Statutes|Title 63. Public Health and Safety|§63-5030.3. Powers and duties of board.

|A. The Medicaid Drug Utilization Review Board shall have the power and duty to: |1. Advise and make recommendations regarding rules promulgated by the Oklahoma Health Care Authority Board to implement the provisions of this act;2. Oversee the development, implementation and assessment of a Medicaid retrospective and prospective drug utilization review program, including making recommendations regarding contractual agreements of the Oklahoma Health Care Authority with any entity involved in processing and reviewing Medicaid drug profiles for the drug utilization review program in accordance with the provisions of this act;3. Develop and apply the criteria and standards to be used in retrospective and prospective drug utilization review. The criteria and standards shall be based on the compendia and federal Food and Drug Act approved labeling, and shall be developed with professional input;4. Provide a period for public comment on each meeting agenda. As necessary, the Medicaid Drug Utilization Review Board may include a public hearing as part of a meeting agenda to solicit public comment regarding proposed changes in the prior authorization program and the retrospective and prospective drug utilization review processes. Notice of proposed changes to the prior authorization status of a drug or drugs shall be included in the monthly meeting agenda at least thirty (30) days prior to the consideration or recommendation of any proposed changes in prior authorization by the Medicaid Drug Utilization Review Board;5. Establish provisions to timely reassess and, as necessary, revise the retrospective and prospective drug utilization review process;6. Make recommendations regarding the prior authorization of prescription drugs pursuant to the provisions of Section 5 of this act; and7. Provide members of the provider community with educational opportunities related to the clinical appropriateness of prescription drugs.B. Any party aggrieved by a decision of the Oklahoma Health Care Authority Board or the Administrator of the Oklahoma Health Care Authority, pursuant to a recommendation of the Medicaid Drug Utilization Review Board, shall be entitled to an administrative hearing before the Oklahoma Health Care Authority Board pursuant to the provisions of the Administrative Procedures Act.Added by Laws 1999, c. 201, § 3, eff. July 1, 1999.
63 OK Stat § 63-5030.4 (2021)
2021 Oklahoma Statutes|Title 63. Public Health and Safety|§63-5030.4. Drug utilization review program.

|1. The Medicaid Drug Utilization Review Board shall develop and recommend to the Oklahoma Health Care Authority Board a retrospective and prospective drug utilization review program for medical outpatient drugs to ensure that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical outcomes. |2. The retrospective and prospective drug utilization review program shall be operated under guidelines established by the Medicaid Drug Utilization Review Board as follows:a.The retrospective drug utilization review program shall be based on guidelines established by the Medicaid Drug Utilization Review Board using the mechanized drug claims processing and information retrieval system to analyze claims data in order to:(1)identify patterns of fraud, abuse, gross overuse or underuse, and inappropriate or medically unnecessary care,(2)assess data on drug use against explicit predetermined standards that are based on the compendia and other sources for the purpose of monitoring:(a)therapeutic appropriateness,(b)overutilization or underutilization,(c)appropriate use of generic drugs,(d)therapeutic duplication,(e)drug-disease contraindications(f)drug-drug interactions,(g)incorrect drug dosage,(h)duration of drug treatment, and(i)clinical abuse or misuse, and(3)introduce remedial strategies in order to improve the quality of care and to conserve program funds or personal expenditures.b.(1)The prospective drug utilization review program shall be based on guidelines established by the Medicaid Drug Utilization Review Board and shall provide that, before a prescription is filled or delivered, a review will be conducted by the pharmacist at the point of sale to screen for potential drug therapy problems resulting from:(a)therapeutic duplication,(b)drug-drug interactions,(c)incorrect drug dosage or duration of drug treatment,(d)drug-allergy interactions, and(e)clinical abuse or misuse.(2)In conducting the prospective drug utilization review, a pharmacist may not alter the prescribed outpatient drug therapy without the consent of the prescribing physician or purchaser.Added by Laws 1999, c. 201, § 4, eff. July 1, 1999.
63 OK Stat § 63-5051.2 (2021)
2021 Oklahoma Statutes|Title 63. Public Health and Safety|§63-5051.2. Right to reimbursement for medical services - Assignment to Oklahoma Health Care Authority.

|A. Whenever the Oklahoma Health Care Authority pays for medical services or renders medical services, for or on behalf of a person who has been injured or suffered an illness or disease, the right of the provider of the services to reimbursement shall be automatically assigned to the Oklahoma Health Care Authority, upon notice to the insurer or other party obligated as a matter of law or agreement to reimburse the provider on behalf of the patient. |B. Upon the assignment, the Authority, for purposes of the claim for reimbursement, becomes a provider of medical services.C. The assignment of the right to reimbursement shall be applied and considered valid against any employer or insurer under the Workers' Compensation Act in this state.D. Each insurer, upon receiving a claim from the Oklahoma Health Care Authority, shall accept the state’s right of recovery, to process and, if appropriate, pay the claim to the same extent that the plan would have been liable if it had been billed at the point of sale or by the original provider of services. Insurer shall not deny the Authority claims on the basis of the date of submission, the format of the claim, or for failure to present proper documentation of coverage at the point of sale.E. Insurer shall make appropriate payments to the Authority as long as the claim is submitted for consideration within three (3) years from the date the service was furnished. Any action by the Authority to enforce the payment of the claim shall be commenced within six (6) years of the submission of the claim by the Authority.Added by Laws 1981, c. 159, § 2, emerg. eff. May 8, 1981. Amended by Laws 1996, c. 221, § 2, eff. Nov. 1, 1996. Renumbered from § 200a of Title 56 by Laws 1996, c. 221, § 6, eff. Nov. 1, 1996. Amended by Laws 2007, c. 74, § 2, eff. Nov. 1, 2007.
63 OK Stat § 63-5051.4 (2021)
2021 Oklahoma Statutes|Title 63. Public Health and Safety|§63-5051.4. Coverage under Medicaid Program Reform Act of 2003 - Enrollment fee and/or premium.

|The Oklahoma Health Care Authority is hereby authorized to charge an enrollment fee and/or premium for the provision of health care coverage under the Oklahoma Medicaid Program Reform Act of 2003. Such charges, if unpaid, create a debt to the state and are subject to recovery by the Authority by any legal action against an enrollee, the heirs or next of kin of the enrollee in the event of the death of the enrollee. The Authority may end coverage for the nonpayment of such enrollment and/or premium pursuant to rules promulgated by the Oklahoma Health Care Authority Board. |Added by Laws 2003, c. 464, § 11, eff. July 1, 2003.
63 OK Stat § 63-5051.5 (2021)
2021 Oklahoma Statutes|Title 63. Public Health and Safety|§63-5051.5. Data files comparisons - File systems maintained by insurers - Exchange of information with Authority.

|A. 1. On or after November 1, 2003, any entity that provides health insurance in this state including, but not limited to, a licensed insurance company, not-for-profit hospital service, medical indemnity corporation, managed care organization, self-insured plan, pharmacy benefit manager or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service is hereby required to compare data from its files with data in files provided to the entity by the Oklahoma Health Care Authority and accept the Authority’s right of recovery and the assignment of rights and not charge the Authority or any of its authorized agents any fees for the processing of claims or eligibility requests. Data files requested by or provided to the Authority shall provide the Authority with eligibility and coverage information that will enable the Authority to determine the existence of third party coverage for Medicaid recipients and the necessary information to determine during what period Medicaid recipients may be or may have been covered by the health insurer and the nature of the coverage that is or was provided, including the name, address, and identifying number of the plan. |2. The insurer shall transmit to the Authority, in a manner prescribed by the Centers for Medicare and Medicaid Services or as agreed between insurer and the Authority, an electronic file of all identified subscribers or policyholders, or their dependents, for whom there is data corresponding to the information contained in subsection C of this section.B. 1. An insurer shall comply with a request under the provisions of this subsection no later than sixty (60) days after the date of transmission by the Authority and shall only be required to provide the Authority with the information required by subsection C of this section.2. The Authority may make such request for data from an insurer no more than once every six (6) months, as determined by the date of the Authority’s original request.C. Each insurer shall maintain a file system containing the name, address, group policy number, coverage type, social security number, and date of birth of each subscriber or policyholder, and each dependent of the subscriber or policyholder covered by the insurer, including policy effective and termination dates, claim submission address, and employer’s mailing address.D. The Oklahoma Health Care Authority Board shall promulgate rules governing the exchange of information under this section. Such rules shall be consistent with all laws relating to the confidentiality or privacy of personal information or medical records including, but not limited to, provisions under the federal Health Insurance Portability and Accountability Act (HIPAA).Added by Laws 2003, c. 464, § 12, eff. July 1, 2003. Amended by Laws 2007, c. 74, § 3, eff. Nov. 1, 2007; Laws 2011, c. 204, § 1, eff. Nov. 1, 2011.
63 OK Stat § 63-5052 (2021)
2021 Oklahoma Statutes|Title 63. Public Health and Safety|§63-5052. Opportunity for hearing before Authority - Record - Review by Administrator - Judicial review.

|A. Any applicant or recipient, adversely affected by a decision of the Oklahoma Health Care Authority on benefits or services provided pursuant to the provisions of this title, shall be afforded an opportunity for a hearing pursuant to the provisions of subsection B of this section after such applicant or recipient has been notified of the adverse decision of the Authority. |B. 1. Upon timely receipt of a request for a hearing as specified in the notice of adverse decision and exhaustion of other available administrative remedies, the Authority shall hold a hearing pursuant to the provisions of rules promulgated by the Oklahoma Health Care Authority Board pursuant to this section.2. The record of the hearing shall include, but shall not be limited to:a.all pleadings, motions and intermediate rulings,b.evidence received or considered,c.any decision, opinion or report by the officer presiding at the hearing, andd.all staff memoranda or data submitted to the hearing officer or members of the agency in connection with their consideration of the case.3. Oral proceedings shall be electronically recorded by the Authority. Any party may request a copy of the tape recording of such person's administrative hearing or may request a transcription of the tape recording to comply with any federal or state law.C. Any decision of the Authority after such a hearing pursuant to subsection B of this section shall be subject to review by the Administrator of the Oklahoma Health Care Authority or designated administrative law judge upon a timely request for review by the applicant or recipient. The Administrator may only designate an administrative law judge at another state agency, as established in the State Medicaid Plan and approved by the Centers for Medicare and Medicaid Services. The Administrator or designated administrative law judge shall issue a decision after review. A hearing decision of the Authority shall be final and binding unless a review is requested pursuant to the provisions of this subsection. The decision of the Administrator or designated administrative law judge may be appealed to the district court in which the applicant or recipient resides within thirty (30) days of the date of the decision of the Administrator or designated administrative law judge as provided by the provisions of subsection D of this section.D. Any applicant or recipient under this title who is aggrieved by a decision of the Administrator or designated administrative law judge rendered pursuant to this section may petition the district court in which the applicant or recipient resides for a judicial review of the decision pursuant to the provisions of Sections 318 through 323 of Title 75 of the Oklahoma Statutes. A copy of the petition shall be served by mail upon the general counsel of the Authority.Added by Laws 1997, c. 137, § 1, emerg. eff. April 22, 1997. Amended by Laws 2021, c. 562, § 1, eff. Nov. 1, 2021.
63 OK Stat § 63-5053 (2021)
2021 Oklahoma Statutes|Title 63. Public Health and Safety|§63-5053. Short title.

|This act shall be known and may be cited as the "Oklahoma Medicaid False Claims Act". |Added by Laws 2007, c. 137, § 1, eff. Nov. 1, 2007.
63 OK Stat § 63-5053.2 (2021)
2021 Oklahoma Statutes|Title 63. Public Health and Safety|§63-5053.2. Civil actions by Attorney General or individual persons authorized - Complaint procedure.

|A. The Attorney General shall diligently investigate a violation under the Oklahoma Medicaid False Claims Act. If the Attorney General finds that a person has violated or is violating the Oklahoma Medicaid False Claims Act, the Attorney General may bring a civil action under this section against the person. |B. 1. A person may bring a civil action for a violation of the Oklahoma Medicaid False Claims Act for the person and for this state. The action shall be brought in the name of the state. The action may be dismissed only if the court and the Attorney General give written consent to the dismissal and state the reasons for consenting.2. A copy of the complaint and written disclosure of substantially all material evidence and information the person possesses shall be served on the state pursuant to Section 2004 of Title 12 of the Oklahoma Statutes. The complaint shall be filed in camera, shall remain under seal for at least sixty (60) days, and shall not be served on the defendant until the court so orders. The state may elect to intervene and proceed with the action within sixty (60) days after it receives both the complaint and the material evidence and information.3. The state may, for good cause shown, move the court for extensions of the time during which the complaint remains under seal under paragraph 2 of this subsection. Any such motions may be supported by affidavits or other submissions in camera. The defendant shall not be required to respond to any complaint filed under this section until twenty (20) days after the complaint is unsealed and served upon the defendant pursuant to Section 2004 of Title 12 of the Oklahoma Statutes.4. Before the expiration of the sixty-day period or any extensions obtained under paragraph 3 of this subsection, the state shall:a.proceed with the action, in which case the action shall be conducted by the state, orb.notify the court that it declines to take over the action, in which case the person bringing the action shall have the right to conduct the action.5. When a person brings an action under this section, no person other than the state may intervene or bring a related action based on the facts underlying the pending action.Added by Laws 2007, c. 137, § 3, eff. Nov. 1, 2007. Amended by Laws 2016, c. 44, § 2, eff. Nov. 1, 2016.
63 OK Stat § 63-5053.5 (2021)
2021 Oklahoma Statutes|Title 63. Public Health and Safety|§63-5053.5. Prohibition of certain individual actions - Dismissal - Liability for expenses or fees - Relief following adverse acts - Statute of limitations.

|A. In no event may a person bring an action under subsection B of Section 5053.2 of this title which is based upon allegations or transactions which are the subject of a civil suit or an administrative civil money penalty proceeding in which the state is already a party. |B. The court shall dismiss an action or claim under this section, unless opposed by the state, if substantially the same allegations or transactions as alleged in the action or claim were publicly disclosed in a criminal, civil or administrative hearing, in which the state or its agent is a party, in a legislative, or State Auditor and Inspector report, hearing, audit or investigation, or from the news media, unless the action is brought by the Attorney General or the person bringing the action is an original source of the information. For purposes of this subsection, "original source" means an individual who either:1. Prior to a public disclosure under subsection B of this section, has voluntarily disclosed to the state the information on which allegations or transactions in a claim are based; or2. Has knowledge that is independent of and materially adds to the publicly disclosed allegations or transactions, and who has voluntarily provided the information to the state before filing an action under the Oklahoma Medicaid False Claims Act.C. The state is not liable for expenses which a person incurs in bringing an action under this section.D. In civil actions brought under this section by this state, the provisions of Title 28 of the Oklahoma Statutes shall apply.E. Any employee, contractor or agent shall be entitled to:1. All relief necessary to make the employee, contractor or agent whole, if the employee, contractor or agent is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment because of lawful acts done by the employee, contractor, agent or associated others in furtherance of an action under this act, or other efforts to stop one or more violations of the Oklahoma Medicaid False Claims Act.2. Relief which shall include reinstatement with the same seniority status the employee, contractor or agent would have had but for the discrimination, two times the amount of back pay, interest on the back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorney fees. An action under this section may be brought in the appropriate district court of the State of Oklahoma for the relief provided in this subsection.F. An action under this section shall not be brought more than three (3) years after the date when the retaliation occurred.Added by Laws 2007, c. 137, § 6, eff. Nov. 1, 2007. Amended by Laws 2009, c. 32, § 2, eff. Nov. 1, 2009; Laws 2016, c. 44, § 5, eff. Nov. 1, 2016; Laws 2017, c. 86, § 2, eff. Nov. 1, 2017.