Claims Review Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Claims Review Sample). The Paid Claims shall be reviewed based on the supporting documentation available at Progenity’s office or under Progenity’s control and applicable Medicare and state Medicaid program requirements to determine whether the medical necessity of the items and services furnished was appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim.
Claims Review Sample. The IRO shall select a random sample of 100 Paid Claims (Claims Review Sample). The IRO shall review the Paid Claims based on Provider’s documentation and the applicable Medicare program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed.
Claims Review Sample. The IRO shall randomly select and review a sample of 30 Patient Stays in the Population at each Subject Facility (each selection of Patient Stays at a Subject Facility shall be referred to as a “Claims Review Sample”). The IRO shall review the Patient Stay and all Paid Claims associated with each selected Patient Stay. The Patient Stay and associated Paid Claims shall be reviewed based on the supporting documentation available at Sava’s office or under Sava’s control, and applicable Medicare program requirements and practice guidelines endorsed by the American Physical Therapy Association, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association to determine whether the items and services furnished were (a) medically necessary and reasonable,
Claims Review Sample. The IRO shall randomly select and review a sample of 50 Paid Claims (Claims Review Sample) for each of the Subject Facilities. The Paid Claims shall be reviewed based on the supporting documentation available at UHS’s or the Subject Facility’s office or under UHS’s control and applicable Medicare program, a state Medicaid program, or the TRICARE program requirements to determine whether the items and services furnished were medically necessary, appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim.
Claims Review Sample. The IRO shall randomly select and review a sample of 50 Paid Claims at each Claims Review Facility (each review at a Claims Review Facility shall be referred to as a “Claims Review Sample”). The Paid Claims in each Claims Review Sample shall be reviewed based on the supporting documentation available at Vibra’s office, any of the Claims Review Facilities, or under Vibra’s control and applicable Medicare and state Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented and whether the Paid Claim in each Claims Review Sample was correctly coded, submitted, and reimbursed pursuant to Medicare LTCH and IRF coverage criteria, as applicable. For each Paid Claim in any Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim. OIG, in its sole discretion, may refer the findings of any Claims Review Sample (and any related work papers) received from Vibra to the appropriate Federal health care program payor (e.g., Medicare contractor) for appropriate follow-up by that payor.
Claims Review Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Claims Review Sample). The Paid Claims reviewed shall be comprised of five strata (Strata) as follows: 15 Basic Life Support Emergency Paid Claims, 30 Basic Life Support Non-Emergency Paid Claims; 15 Advanced Life Support Emergency Paid Claims, 30 Advanced Life Support Non-Emergency Paid Claims, and 10 other Paid Claims. Each Strata shall be reviewed separately. The Paid Claims shall be reviewed based on the supporting documentation available at Liberty’s office or under Liberty’s control and applicable Medicare and state Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim.
Claims Review Sample. Prior to the end of each Reporting Period, CHN shall furnish to the IRO a list that identifies the top five CHN hospitals based upon amounts received for Paid Claims together with the amounts received for Paid Claims by each of these CHN hospitals during the Reporting Period. The IRO shall randomly select two of these hospitals (each a Selected CHN Hospital). For each of the Selected CHN Hospitals, the IRO shall select a random sample of 100 Paid Claims (each a Claims Review Sample). The IRO shall review the Paid Claims based on CHN’s documentation and the applicable Medicare program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed.
Claims Review Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Claims Review Sample) at each Selected Facility. The Paid Claims shall be reviewed based on the supporting documentation available at Prime’s office or under Prime’s control to determine whether the inpatient admission and length of stay were medically necessary and appropriate under the applicable Medicare program requirements. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that resulted in the identified Overpayment. The IRO shall provide its observations and recommendations on suggested improvements to the relevant system(s) and the process(es).
Claims Review Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Claims Review Sample). The Paid Claims shall be reviewed based on the supporting documentation available at Arc’s office or under Arc’s control and applicable Alaska Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim. In connection with its review of the Claims Review Sample, the IRO shall also review Arc’s billing system (currently, the Medi-Track System) to determine whether Arc has a process for accurately tracking and reporting voided and adjusted claims, and provide its observations and recommendations on suggested improvements (if any).
Claims Review Sample. Prior to the end of each Reporting Period, Apria shall furnish to the IRO a list of the top 50 Apria locations based upon amounts received for Paid Claims together with the amounts received for Paid Claims by each of these locations during the Reporting Period (Apria Locations). The IRO shall randomly select four of these Apria Locations (Selected Apria Locations). The IRO shall randomly select and review a sample of 50 Paid Claims from each of the four Selected Apria Locations. Each sample of 50 Paid Claims from a Selected Apria Location shall be referred to as a Claims Review Sample for purposes of this Appendix. The Paid Claims for each Claims Review Sample shall be reviewed based on the supporting documentation available at Apria or under Apria’s control and applicable Medicare and state Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim.
