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1 STATE OF OKLAHOMA
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2 2nd Session of the 60th Legislature (2026)
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3 SENATE BILL 1645 By: Gollihare
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6 AS INTRODUCED
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7 An Act relating to the state Medicaid program;
7 defining terms; establishing certain requirements and
8 procedures for audits of long-term care providers;
8 directing the Oklahoma Health Care Authority to
9 establish certain appeals process; providing for
9 review by administrative law judge; authorizing
10 certain judicial review; prohibiting certain adverse
10 action by the Authority; stipulating certain
11 requirements for recoupment of funds; limiting
11 applicability of certain provisions; directing
12 promulgation of rules; providing for codification;
12 and providing an effective date.
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15 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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16 SECTION 1. NEW LAW A new section of law to be codified
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17 in the Oklahoma Statutes as Section 5051.11 of Title 63, unless
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18 there is created a duplication in numbering, reads as follows:
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19 A. As used in this section:
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20 1. "Audit" means any review, analysis, or investigation
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21 conducted by the Oklahoma Health Care Authority or an entity on its
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22 behalf of a Medicaid claim submitted by a long-term care provider if
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23 the review, analysis, or investigation:
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1 a. may result in recoupment, withholding, denial, or
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2 adjustment of Medicaid payments, and
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3 b. involves records, documents, or information other than
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4 the filed claim;
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5 2. "Clerical or recordkeeping error" means a mistake or an
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6 omission in the filed claim regarding a required document or record.
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7 A clerical or recordkeeping error includes, but is not limited to,
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8 a:
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9 a. typographical error,
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10 b. scrivener's error, or
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11 c. computer error; and
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12 3. "Long-term care provider" means a:
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13 a. nursing facility,
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14 b. intermediate care facility for individuals with
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15 intellectual disabilities (ICF/IID),
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16 c. Medicaid home- and community-based services provider,
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17 or
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18 d. program of all-inclusive care for the elderly (PACE)
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19 organization,
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20 that is contracted with the Authority to provide services to members
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21 of the state Medicaid program.
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22 B. Subject to applicable federal law, when the Oklahoma Health
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23 Care Authority conducts an audit of a long-term care provider, the
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1 audit shall be conducted according to the following requirements and
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2 procedures:
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3 1. The Authority shall give the long-term care provider notice
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4 of the audit at least one (1) week before conducting the initial
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5 audit for each audit cycle;
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6 2. a. An audit that involves the application of clinical or
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7 professional judgment shall be conducted in
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8 consultation with any state agency that licenses,
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9 contracts with, or oversees the long-term care
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10 provider.
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11 b. The Authority shall not cite a long-term care provider
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12 that is contracted with a state agency other than the
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13 Authority for delivery of Medicaid services for an
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14 error based on an act or omission that complied with
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15 applicable rules, policies, or guidance of such state
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16 agency;
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17 3. a. A clerical or recordkeeping error shall not:
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18 (1) constitute fraud, or
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19 (2) be subject to criminal penalties without proof of
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20 intent to commit fraud.
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21 b. A claim arising under subparagraph a of this paragraph
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22 may be subject to recoupment;
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1 4. Submission of a corrected claim by a long-term care provider
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2 shall not constitute an admission of liability, fault, or
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3 wrongdoing;
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4 5. a. When an audit is for a specifically identified problem
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5 that has been disclosed to the long-term care
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6 provider, the audit shall be limited to a claim that
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7 is identified by a claim number.
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8 b. For an audit other than that described in subparagraph
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9 a of this paragraph, the audit shall be limited to the
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10 greater of:
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11 (1) fifty claims, or
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12 (2) twenty-five one-hundredths percent (0.25%) of the
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13 number of claims billed by the long-term care
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14 provider to the auditor in the previous calendar
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15 year.
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16 c. If an audit reveals the necessity for a review of
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17 additional claims, the audit shall be conducted by one
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18 of the following methods at the discretion of the
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19 long-term care provider:
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20 (1) on-site,
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21 (2) electronically, or
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22 (3) by the same method as the initial audit.
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23 d. Except for an audit initiated under subparagraph a of
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24 this paragraph, the Authority shall not initiate an
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1 audit of a long-term care provider more than two (2)
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2 times in a calendar year;
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3 6. A recoupment shall not be based on:
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4 a. documentation requirements in addition to the
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5 requirements for creating or maintaining documentation
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6 prescribed by state law or rule or federal law or
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7 regulation, or
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8 b. a requirement that a long-term care provider perform
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9 professional duties prescribed by state law or rule or
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10 federal law or regulation;
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11 7. a. Recoupment shall only occur following the correction
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12 of a claim and shall be limited to amounts paid in
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13 excess of amounts payable under the corrected claim.
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14 b. The Authority may recoup the entire overpaid claim if
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15 payment is issued for the corrected claim on the same
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16 date.
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17 c. Following a notice of overpayment, a long-term care
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18 provider shall have at least sixty (60) days to file a
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19 corrected claim;
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20 8. Approval of a service, long-term care provider, or patient
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21 eligibility upon adjudication of a claim shall not be reversed
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22 unless the long-term care provider obtained the adjudication by
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23 fraud or misrepresentation of claim elements;
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1 9. Each long-term care provider shall be audited by the
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2 Authority under the same standards and parameters;
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3 10. The Authority shall disclose to long-term care providers
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4 all policies, manuals, billing guidelines, and audit criteria and
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5 any changes to such policies, manuals, guidelines, and criteria. No
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6 recoupment may be based on undisclosed or retroactively applied
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7 criteria;
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8 11. A long-term care provider shall be allowed at least sixty
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9 (60) days following receipt of the preliminary audit report in which
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10 to produce documentation to address any discrepancy found during the
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11 audit;
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12 12. The period covered by an audit shall not exceed twenty-four
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13 (24) months from the date the claim was submitted to the Authority;
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14 13. a. The preliminary audit report under paragraph 11 of
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15 this subsection shall be delivered to a long-term care
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16 provider within one hundred twenty (120) days after
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17 the conclusion of the audit.
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18 b. A final audit report shall be delivered to the long-
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19 term care provider within six (6) months after receipt
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20 of the preliminary audit report or receipt of the
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21 final appeal as provided for in this subsection,
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22 whichever is later; and
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23 14. Notwithstanding any other provision in this section, the
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24 Authority shall not use the accounting practices of statistical
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1 sampling, projection, or extrapolation methodologies to calculate
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2 alleged overpayments, recoupments, or penalties for audits.
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3 C. 1. The Authority shall establish an appeals process under
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4 which a long-term care provider may appeal a final audit report to
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5 the Authority. A decision of the Authority after the appeal shall
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6 be final and binding unless a review is requested under paragraph 2
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7 of this subsection.
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8 2. Any decision of the Authority after the appeal shall be
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9 subject to review by an administrative law judge designated by the
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10 Administrator of the Oklahoma Health Care Authority upon a timely
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11 request for review by the applicant or recipient. The Administrator
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12 may only designate an administrative law judge at another state
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13 agency, as established in the State Medicaid Plan and approved by
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14 the Centers for Medicare and Medicaid Services. The designated
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15 administrative law judge shall issue a decision after review.
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16 3. Any applicant or recipient under this title who is aggrieved
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17 by a decision of the designated administrative law judge rendered
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18 under paragraph 2 of this subsection may petition the district court
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19 in which the long-term care provider is located within thirty (30)
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20 days of the date of the decision for a judicial review of the
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21 decision pursuant to the provisions of Sections 318 through 323 of
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22 Title 75 of the Oklahoma Statutes. A copy of the petition shall be
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23 served by mail upon the general counsel of the Authority.
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1 D. The Authority shall not take adverse action against a long-
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2 term care provider for exercising rights conferred by this section
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3 including, but not limited to, retaliation through selection for
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4 additional audits.
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5 E. A recoupment of any disputed funds shall only occur after
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6 final disposition of the audit, including the appeals processes
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7 described in subsection C of this section.
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8 F. The total amount of any recoupment on an audit shall be
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9 refunded to:
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10 1. The state agency responsible for paying the state share of
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11 the Medicaid services provided by the long-term care provider, if an
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12 agency other than the Authority; or
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13 2. In the absence of the conditions described in paragraph 1 of
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14 this subsection, the Authority.
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15 G. This section does not apply to any audit, review, or
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16 investigation that involves alleged fraud, willful
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17 misrepresentation, or abuse.
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18 H. The Oklahoma Health Care Authority Board shall promulgate
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19 rules to implement the provisions of this section.
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20 SECTION 2. This act shall become effective January 1, 2027.
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22 60-2-2888 DC 1/13/2026 7:45:25 PM
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Req. No. 2888 Page 8Every fact on this page links to its source, starting with the official bill record.