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Claim Reviews Sample Clauses

Claim Reviews a. Retrospective reviews on opioid prescriptions exceeding state defined limitations on an ongoing basis. b. Retrospective reviews on concurrent utilization of opioids and benzodiazepines as well as opioids and antipsychotics on an ongoing periodic basis.
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Claim Reviews. A review by the Reinsurer along with its claims paying Designee of the underwriting of a particular risk must be based on the Underwriting Guidelines of the Company. Further, the review may include facts that should have been known as a result of diligent inquiry so long as, based upon the known facts, a reasonably prudent underwriter would have been expected to make further inquiry. If, as part of examining a claim in accordance with Article 8, “Death Claims”, or inspecting the Company’s records in accordance with Article 16, “Inspection of Records”, the Reinsurer or its claims paying Designee finds that the underwriting assessment of a Policy was not consistent with the Underwriting Guidelines and/or the Prudent Underwriter Standard, the remedy will be a retroactive adjustment of any premiums and considerations, with interest. The Reinsurer, along with its claims paying Designee, shall not deny the claim payment or rescind coverage unless it assesses the risk in question as uninsurable.
Claim Reviews. The CIPF shall establish within its Coverage Policies a fair and reasonable internal claim review process whereby customer claims that are not accepted for payment by the CIPF staff or by an appointed committee shall be reconsidered by the Board of Governors or a review panel if requested by the Customer or CIPF staff. The Coverage Policies shall include criteria established by the Board of Governors for the selection of the review panel members.
Claim Reviews. For each claim selected in the first and second stage, the associated MDS and the medical record documentation supporting the MDS will be reviewed. The review process shall entail an evaluation of the MDS and verification that each entry that affects the RUG code outcome for the MDS is supported by the medical record for the corresponding period of time consistent with the assessment reference date ("ARD") specified on the MDS. In addition, data from the MDS will be re-entered into Beverly's Grouper (MDS data entry software program) to verify that the correct RUG code assignment was properly assigned on the UB-92. A financial error will be logged if there is insufficient support for an MDS data point(s) that results in a downward change in RUG assignment that would result in an overpayment.

Related to Claim Reviews

  • Log Reviews All systems processing and/or storing PHI COUNTY discloses to 11 CONTRACTOR or CONTRACTOR creates, receives, maintains, or transmits on behalf of COUNTY 12 must have a routine procedure in place to review system logs for unauthorized access.

  • Post Review With respect to each contract not governed by paragraph 2 of this Part, the procedures set forth in paragraph 4 of Appendix 1 to the Guidelines shall apply.

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