Claims Review Findings a. Narrative Results.
i. A description of CFS’s billing and coding system(s), including the identification, by position description, of the personnel involved in coding and billing.
ii. A description of controls in place at CFS to ensure that all items and services furnished by CFS are correctly coded, appropriately documented, and medically necessary.
iii. A narrative explanation of the results of the IRO’s review of the Claims Review Sample, including an explanation of all errors identified by the IRO.
b. Quantitative Results.
i. Total number and percentage of instances in which the IRO determined that the coding of the Paid Claims submitted by CFS differed from what should have been the correct coding.
ii. Total number and percentage of instances in which the IRO determined that a Paid Claim was not appropriately documented.
iii. Total number and percentage of instances in which the IRO determined that a Paid Claim was for items or services that were not medically necessary.
iv. Total dollar amount of Paid Claims included in the Claims Review Sample and the net Overpayment associated with the Claims Review Sample.
v. Error Rate in the Claims Review Sample.
Claims Review Findings a. Narrative Results.
i. A description of THM’s billing and coding system(s), including the identification, by position description, of the personnel involved in coding and billing.
ii. A description of controls in place at THM to ensure that all items and services billed to a state Medicaid program or Medicaid managed care program are medically necessary and appropriately documented.
iii. A narrative explanation of the IRO’s findings and supporting rationale (including reasons for errors, patterns noted, etc.) regarding the Claims Review, including the results of the Claims Review Sample.
b. Quantitative Results.
i. Total number and percentage of instances in which the IRO determined that the coding of the Paid Claims submitted by THM differed from what should have been the correct coding and in which such difference resulted in an Overpayment to THM.
ii. Total number and percentage of instances in which the IRO determined that a Paid Claim was not appropriately documented and in which such documentation errors resulted in an Overpayment to THM.
iii. Total number and percentage of instances in which the IRO determined that a Paid Claim was for items or services that were not medically necessary and resulted in an Overpayment to THM.
iv. Total dollar amount of all Overpayments in the Claims Review Sample.
v. Total dollar amount of Paid Claims included in the Claims Review Sample.
vi. Error Rate in the Claims Review Sample. The Error Rate shall be calculated by dividing the Overpayment in the Claims Review Sample by the total dollar amount associated with the Paid Claims in the Claims Review Sample.
vii. An estimate of the actual Overpayment in the Population at the mean point estimate.
viii. A spreadsheet of the Claims Review results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, code submitted (e.g., DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference
Claims Review Findings a. Narrative Results.
i. A description of Xxx’s billing and coding system(s), including the identification, by position description, of the personnel involved in coding and billing.
ii. A description of controls in place at Arc to ensure that all items and services billed to the Alaska Medicaid program are medically necessary and appropriately documented.
iii. A description of Xxx’s billing and claims reconciliation system, and the processes and controls used to track and report voided and adjusted claims.
iv. A narrative explanation of the IRO’s findings and supporting rationale (including reasons for errors, patterns noted, etc.) regarding the Claims Review, including the results of the Claims Review Sample.
b. Quantitative Results.
i. Total number and percentage of instances in which the IRO determined that the coding of the Paid Claims submitted by Arc differed from what should have been the correct coding and in which such difference resulted in an Overpayment to Arc.
ii. Total number and percentage of instances in which the IRO determined that a Paid Claim was not appropriately documented and in which such documentation errors resulted in an Overpayment to Arc.
iii. Total number and percentage of instances in which the IRO determined that a Paid Claim was for items or services that were not medically necessary and resulted in an Overpayment to Arc.
iv. Total dollar amount of all Overpayments in the Claims Review Sample.
v. Total dollar amount of Paid Claims included in the Claims Review Sample.
Claims Review Findings a. Narrative Results.
i. A description of AAMC’s billing and coding system(s), including the identification, by position description, of the personnel involved in coding and billing.
ii. A description of controls in place at AAMC to ensure that all items and services billed to Medicare, a state Medicaid program, or the TRICARE program are medically necessary and appropriately documented.
iii. A narrative explanation of the IRO’s findings and supporting rationale (including reasons for errors, patterns noted, etc.) regarding the Claims Review, including the results of each Claims Review Sample.
Claims Review Findings a. Narrative Results.
i. A description of Pentec’s billing system(s), including the identification, by position description, of the personnel involved in billing.
ii. A description of controls in place at Pentec to ensure that all prescription drugs billed to Medicare are supported by prescriptions from authorized prescribers, are dispensed as prescribed, and otherwise meet all Medicare program requirements.
iii. A narrative explanation of the IRO’s findings and supporting rationale (including reasons for errors, patterns noted, etc.) regarding the Claims Review, including the results of the Claims Review Sample.
b. Quantitative Results.
i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by Pentec were not supported by prescriptions from authorized prescribers or did not otherwise meet all Medicare requirements and in which such error(s) resulted in an Overpayment to Pentec.
ii. Total dollar amount of all Overpayments in the Claims Review Sample.
iii. Total dollar amount of Paid Claims included in the Claims Review Sample.
Claims Review Findings a. Narrative Results.
i. A description of Xxxxxxxxx’s billing and coding system(s), including the identification, by position description, of the personnel involved in coding and billing.
ii. A description of controls in place at Millcreek to ensure that all items and services billed to Medicare or a state Medicaid program are medically necessary and appropriately documented.
iii. A narrative explanation of the IRO’s findings and supporting rationale (including reasons for errors, patterns noted, etc.) regarding the Claims Review, including the results of each Claims Review Sample.
Claims Review Findings
