Notification of Fraud, Willful Misrepresentation, or Abuse (FWA) Audit

Please submit this form for all audits conducted due to suspicion of FWA. Feel free to submit any questions regarding this process to PBMAudit@oag.ok.gov. Thank you.

PBM / Auditing Entity

Audit Contact person

Who can OAG representatives contact for information regarding this notification?

Contact Email

Contact Phone

Phone

Pharmacy Name

What is the name of the pharmacy subject to the audit?

NCPDP

NCPDP ID number for subject pharmacy

Pharmacy's Address

Pharmacy's Address 2

Pharmacy's City

Pharmacy's Zip Code

PSAO/Contracting Agent

Audit ID

Audit_Type

Audit Period

Range of dates of Service

Expected State Date

Brief Explanation for FWA Audit

Auditor Name

Auditor ID (if any)

File Upload

Please upload a full list of the claims/prescriptions included in the review. A template is provided on the website.

The list of claims should include the prescription number, BIN, Group ID, PCN, Fill Date, Paid Amount, NDC, Label Name, Network Reimbursement ID, and Plan name for each claim reviewed.

Drop your files here

Send me a copy of my responses

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