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317:2-1-7. Oklahoma Health Care Authority Audit
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Revised 11-15-10
All appeals related to audits and/or reviews resulting in overpayments are heard by an OHCA Administrative Law Judge.
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(1) If a provider disagrees with a decision of an OHCA audit, which has determined that the provider has received an overpayment, the provider may appeal, within 20 days of the date of that decision by submitting an LD-2 form to OHCA's docket clerk.
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(2) The appeal will be commenced by the receipt of an LD-2 form from the appellant provider. The form must set out with specificity, the overpayment decision to which the provider objects along with the grounds for appeal. The provider should explain in detail, the factual and/or legal basis for disagreement with the allegedly erroneous decision. All relevant exhibits the provider believes necessary to decide the appeal should be attached to the LD-2 form, including the following:
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(A) Citations for any statute or rule that the provider feels has been violated;
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(B) The provider's name, address and telephone number;
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(C) The name, address, and phone number of the provider's representative, if any; and
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(D) The LD-2 must be signed by the provider or provider's representative.
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(3) Upon receipt of the appeal by the docket clerk, the matter will be docketed for a hearing before an OHCA Administrative Law Judge.
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(4) Any change in contact information during the course of the appeal should be immediately reported to the OHCA docket clerk.
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(5) The OHCA, on its own initiative or upon written request of a party, may consolidate or join appeals if to do so will expedite the processing of the appeals and not adversely affect the interest of the parties.
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(6) Within 45 days of the LD-2 being received and filed by the OHCA, any settlement discussions being held by the parties must be finalized. Settlement or mediation of audit disputes is encouraged and can begin at any time of the audit process between the provider and OHCA's Legal Division. If settlement is reached, the terms shall be set out in writing and signed by both parties and/or their representatives. Upon the finalization and signature of the settlement agreement, the appeal(s) shall be dismissed.
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(7) Audit appeals which are not settled will commence with a prehearing conference before the assigned administrative law judge as follows:
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(A) At the conference the parties shall clarify and isolate the legal and factual issues involved in the audit appeal.
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(B) Each party shall be present, on time and prepared. Failure to do so may result in dismissal of the appeal or other sanctions unless good cause is shown.
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(C) Prior to the prehearing conference each party shall file with the OHCA and provide a copy to the other party:
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(i) A brief statement of his or her case, to include a list of stipulations and legal and factual issues to be heard;
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(ii) A list of any witnesses who have direct knowledge of the facts surrounding the issues of the appeal and who are expected to be called at the hearing. The list shall include a brief statement of the testimony each witness will offer;
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(iii) A list of any documents and exhibits and the original or a copy of each document or exhibit to be offered into evidence or presented at the hearing; and
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(iv) Any requirements or requests for discovery.
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(D) Administrative Law Judge shall:
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(i) hear and rule on pending requests or motions;
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(ii) rule on whether or not witnesses have knowledge of the facts at issue;
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(iii) rule on whether or not documents and exhibits are relevant;
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(iv) rule on whether or not discovery requests and other motions and requests are relevant;
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(v) strike or deny witnesses, documents, exhibits, discovery requests and other requests or motions which are cumulative, not relevant or not material, used as a means of harassment, unduly burdensome or not timely filed; and
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(vi) identify and rule on errors being appealed and issues to be heard at the administrative hearing.
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(E) The prehearing conference shall be informal, structured by the administrative law judge and not open to the public. The administrative law judge shall record the prehearing conference by digital recording.
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(i) Each party shall be notified of the date of the prehearing conference at least 10 calendar days prior to the scheduled prehearing conference.
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(ii) Witnesses shall not appear or present testimony at the prehearing conference.
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(F) A request for continuance of a prehearing conference can be made up to three days prior to the scheduled prehearing conference date. A lesser period of time may be permitted for good cause shown. The administrative judge shall rule on the request and in no case shall a combination of continuances exceed a total of 30 calendar days except for good cause shown.
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(G) The administrative judge shall issue a prehearing conference statement setting out the witnesses, exhibits, documents and issues to be presented at the hearing; the hearing date; the decisions reviewed and made during the prehearing conference and any stipulations agreed to by the parties.
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(8) The hearing shall be digitally recorded and closed to the public.
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(9) The administrative law judge should attempt to make the final hearing decision within 180 days from the date of the prehearing conference. The final order shall be the entire record of the appeal. Pursuant to Administrative Procedures Act, the Order does not need to contain findings of fact or conclusions of law. The final order is the final decision and is not appealable to the CEO.
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