Common use of Claims Review Findings Clause in Contracts

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 THMMTL’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 MTL to ensure that all items and services billed to Medicare or 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.‌‌Results. For each Strata, please provide:‌‌‌‌ i. Total number and percentage of instances in which the IRO determined that the coding of the Paid Claims submitted by THM MTL differed from what should have been the correct coding and in which such difference resulted in an Overpayment to THMMTL. 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 THMMTL. 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 THMMTL. 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., DRGHCPCS, 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 difference‌difference between allowed amount reimbursed by payor and the correct allowed amount.‌

Claims Review Findings. a. Narrative Results.‌‌ i. A description of THMUHealth’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 UHealth to ensure that all items and services billed to a Medicare or state Medicaid program or Medicaid managed care program are medically necessary and necessary, appropriately documented, and correctly coded, submitted and reimbursed (including but not limited to a description of controls related to Place of Service coding). 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 UHealth differed from what should have been the correct coding and in which such difference resulted in an Overpayment to THMUHealth. 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 THMUHealth. 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 THMUHealth. 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 For the first Quarterly Claims Review Report only, a description of THM(a) LabTox’s billing and coding system(s), including the identification, by position description, of the personnel involved in coding and billing. ii. A , and (b) a description of controls in place at THM to ensure that all items and services billed to Medicare, state Medicaid, or a state Medicaid Managed Care program or Medicaid managed care program by LabTox are medically necessary and appropriately documented. Subsequent Quarterly Claims Review Reports should describe any significant changes to items (a) and (b) or, if no significant changes were made, state that the systems and controls remain the same as described in the prior Quarterly Claims Review Report. iiiii. A narrative explanation of the IRO’s findings and supporting rationale (results of the Quarterly Claims Sample, 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 LabTox differed from what should have been the correct coding and in which such difference resulted in an Overpayment to THMLabTox. 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 THMLabTox. 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 THMLabTox. iv. Total dollar amount of all Overpayments in the Quarterly Claims Review Sample.‌ v. Total dollar amount of Paid Claims included in the Quarterly Claims Review Sample.‌ vi. Error Rate in the Quarterly Claims Review Sample. The Error Rate shall be calculated by dividing the Overpayment in the Quarterly Claims Review Sample by the total dollar amount associated with the Paid Claims in the Quarterly Claims Review Sample. vii. An estimate of the actual Overpayment in the Population at the mean point estimate. viii. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submitted (e.g.submitted, DRG, CPT code, etc.), procedure code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference‌difference between allowed amount reimbursed by payor and the correct allowed amount.

Claims Review Findings. a. Narrative Results.‌‌ i. A description of THMLincare’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 Lincare to ensure that all items and services billed to the Medicare program or a state Medicaid program or Medicaid managed care program are medically necessary and appropriately documented. iii. A description of controls in place at Lincare to ensure that all coinsurance, copayment, and deductible amounts are properly charged to and collected from Medicare and state Medicaid program beneficiaries and that any waivers or reductions of coinsurance, copayment, and deductible amounts are granted in compliance with the Anti-Kickback Statute and the beneficiary inducement prohibitions of the CMPL and Lincare’s policies and procedures, and are appropriately documented. 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 THM Lincare differed from what should have been the correct coding and in which such difference resulted in an Overpayment to THMLincare. 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 THMLincare. 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 THMLincare. iv. Total number and percentage of instances in which the IRO determined that the appropriate coinsurance, copayment, and/or deductible amount associated with any Paid Claim was not charged to and collected from Medicare and state Medicaid program beneficiaries and a waiver or reduction in the appropriate coinsurance, copayment and/or deductible amount was not granted and documented in compliance with the Anti-Kickback Statute and the beneficiary inducement prohibitions of the CMPL and/or Lincare’s policies and procedures. v. Total dollar amount of all Overpayments in the Claims Review Sample.‌Sample. v. vi. 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 THMGuardian’s billing and coding system(s), including the identification, by position description, of the personnel involved in the coding and billing.billing.‌ ii. A description of the controls in place at THM Guardian to ensure that all items and services billed to a state Medicaid program or Medicaid managed care program Medicare Part A are medically necessary and reasonable, appropriate and sufficient to meet the needs of a patient in the assigned Case Mix Groups, 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 SampleSample and the IRO’s findings regarding items A.3.a-h above. 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 Guardian differed from what should have been the correct coding and in which such difference resulted in an Overpayment to THMGuardian. 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 THMGuardian. 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 THMGuardian. iv. Total number and percentage of instances in which the IRO determined that a Paid Claim was for items and services that were not appropriate and sufficient to meet the needs of a patient in the assigned Case Mix Groups and resulted in an Overpayment to Guardian.‌ v. Total dollar amount of all Overpayments in the Claims Claim Review Sample.‌ v. vi. Total dollar amount of Paid Claims included in the Claims Review Sample.‌ vivii. 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. viiviii. An estimate of the actual Overpayment in the Population at the mean point estimate. viiiix. A spreadsheet of the Claims Review results for each Subject Facility that includes the following information for each selected Patient Stay and the associated Paid ClaimClaims: the Federal health care program billed, ; beneficiary health insurance claim number, date dates of service, code submitted (e.g., DRG, CPT PDPM or RUG 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 difference‌difference between allowed amount reimbursed by payor and the correct allowed amount.