Appropriate Level of Services Review Sample Clauses

Appropriate Level of Services Review. The Appropriate Level of Services Review shall consist of a review to ensure that the medical record supports the appropriateness of the Level of Services billed during the Selected Claim Period and that the claim was properly submitted to and reimbursed by Medicare. This review shall be completed for each beneficiary in the Beneficiary Sample who was determined to be eligible for hospice services during the Selected Claim Period. The IRO shall review medical records for the Medicare beneficiaries selected based on the supporting documentation available at VITAS's offices or under VITAS's control and applicable billing and coding regulations and guidance to determine the appropriateness of the Level of Services billed and reimbursed.
Sample 1
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Appropriate Level of Services Review. The Appropriate Level of Services Review shall consist of a review to ensure that the medical record supports the appropriateness of the Level of Services billed during the Selected Claim Period and that the claim was properly submitted to and reimbursed by Medicare. This review shall be completed for each beneficiary in the Beneficiary Sample who was determined to be eligible for hospice services during the Selected Claim Period. The IRO shall review medical records for the Medicare beneficiaries selected based on the supporting documentation available at VITAS’s offices or under VITAS’s control and applicable billing and coding regulations and guidance to determine the appropriateness of the Level of Services billed and reimbursed. For any beneficiary in the Beneficiary Sample that results in a determination by the IRO that the Level of Services billed was not appropriate, the IRO shall review all claims for hospice services for that beneficiary where the Level of Services billed was above Routine Home Care. The IRO shall submit a supplemental report no later than 90 days after the IRO completes its report. VITAS shall refund any Overpayments identified as a result of this additional review and documentation of the refund of any identified Overpayments shall be made available to OIG upon request. Additionally, the IRO shall perform a review of the system(s) and process(es) that resulted in VITAS’s erroneous determination that medical necessity existed for the Level of Services billed, to identify any problems or weaknesses that may have resulted in the identified error(s). The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) for determining medical necessity for the Level of Services provided.
Sample 1
Appropriate Level of Services Review. The Appropriate Level of Services Review shall consist of a review to ensure that the medical record supports the appropriateness of the Level of Services provided and that the claim was properly submitted to and reimbursed by Medicare or Medicaid. This review shall be completed for each beneficiary in the Beneficiary Sample who was determined to be eligible for hospice services for one or more Claim Periods. The IRO shall review medical records for the Medicare and Medicaid beneficiaries selected based on the supporting documentation available at HOK’s offices or under HOK’s control and applicable billing and coding regulations and guidance to determine the appropriateness of the Level of Services billed and reimbursed.‌ For any beneficiary in the Beneficiary Sample that results in a determination by the IRO that the Level of Services billed was not appropriate, the IRO shall perform a review of the system(s) and process(es) that resulted in XXX’s erroneous determination that medical necessity existed for the Level of Services billed, to identify any problems or weaknesses that may have resulted in the identified error(s). The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) for determining medical necessity for the Level of Services provided.
Sample 1

Related to Appropriate Level of Services Review

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