Common use of Claims Review Sample Clause in Contracts

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 Medicaid Paid Claims from the Population for each Selected Location (each set of 50 Paid Claims shall be considered a “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 FacilityDOCS’s office or under UHSDOCS’s control and applicable Medicare program, a state and Medicaid program, or the TRICARE program requirements to determine whether the items and services furnished were medically necessary, 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.Claim.‌‌

Claims Review Sample. The Claims Review IRO shall randomly select and review a sample of 50 100 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 Xxxxxxx’ office or under UHS’s Xxxxxxx’ control and applicable Medicare program, a and state Medicaid program, or the TRICARE program requirements to determine whether the items and services furnished were medically necessary, necessary and appropriately documented, 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 Claims Review 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 Claims Review 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 50 100 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 PGS’ office or under UHS’s PGS’ control and applicable Medicare program, a and state Medicaid program, or the TRICARE program requirements to determine whether the items and services furnished were medically necessary, necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim claim in the Claims Review Sample that results resulted in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim 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 Claimclaim. OIG, in its sole discretion, may refer the findings of the Claims Review Sample (and any related work papers) received from PGS 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 50 Paid Claims from the Population for each Selected Location (each set of 50 Paid Claims shall be considered a “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 FacilityPFH’s office or under UHSPFH’s control and applicable Medicare programMedicare, a and state Medicaid program, or the TRICARE program requirements to determine whether the items and services furnished were medically necessary, 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. The IRO shall randomly select and review a sample of 50 Paid Claims at each Subject Facility (each selection of Paid Claims at a Subject Facility shall be referred to as a “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 FacilityTHM’s office or under UHSTHM’s control and applicable Medicare program, a state Medicaid program, program or the TRICARE Medicaid managed care program requirements to determine whether the items and services furnished were medically necessary, necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the each 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 50 100 Paid Claims from each of the PPOA Locations selected by the OIG (Claims Review Sample) for each of the Subject FacilitiesSamples). The Paid Claims shall be reviewed based on the supporting documentation available at UHS’s or the Subject Facility’s office PPOA Location or under UHSthe PPOA Location’s control and applicable Medicare program, a and state Medicaid program, or the TRICARE program requirements (including Medicare and Medicaid managed care programs) to determine whether the items and services furnished were medically necessary, necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the each 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.