Common use of Claims Review Sample Clause in Contracts

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.

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.. Apria - Corporate Integrity Agreement Appendix B

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 50 100 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 AppendixSample). The Paid Claims for each Claims Review Sample shall be reviewed based on the supporting documentation available at Apria Lincare’s office or under ApriaLincare’s control and applicable Medicare and state Medicaid program requirements and, in the case of managed care plans, applicable contractual 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, and whether the appropriate coinsurance, copayment, and deductible amount was properly charged and collected from the applicable program beneficiary. For any Paid Claim for which a coinsurance, copayment, or deductible amount was reduced or waived, the IRO shall determine whether such reduction or waiver was made and documented in compliance with the requirements of the Anti-Kickback Statute, the beneficiary inducement prohibitions of the Civil Monetary Penalties Law (CMPL) and Lincare’s policies and procedures. 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 1 For purposes of this Appendix B, all references to “Medicare and state Medicaid programs” shall include Medicare and state Medicaid managed care programs.‌ 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, 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 at each of the four Selected Apria Locations. Each sample of 50 Paid Claims from Review Facility (each review at a Selected Apria Location Claims Review Facility shall be referred to as a “Claims Review Sample for purposes of this AppendixSample”). The Paid Claims for in each Claims Review Sample shall be reviewed based on the supporting documentation available at Apria Vibra’s office, any of the Claims Review Facilities, or under ApriaVibra’s control and applicable Medicare and state Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, documented and whether the claim Paid Claim in each Claims Review Sample was correctly coded, submitted, and reimbursedreimbursed pursuant to Medicare LTCH and IRF coverage criteria, as applicable. For each Paid Claim in the any Claims Review Sample that results 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 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.