IRO Qualifications The IRO shall. 1. assign individuals to conduct the Claims Review who have expertise in the Medicare and state Medicaid program requirements applicable to the claims being reviewed;
2. assign individuals to design and select the Claims Review sample who are knowledgeable about the appropriate statistical sampling techniques;
3. assign individuals to conduct the coding review portions of the Claims Review who have a nationally recognized coding certification and who have maintained this certification (e.g., completed applicable continuing education requirements);
4. assign licensed nurses or physicians with relevant education, training and specialized expertise (or other licensed health care professionals acting within their scope of practice and specialized expertise) to make the medical necessity determinations required by the Claims Review; and
5. have sufficient staff and resources to conduct the reviews required by the CIA on a timely basis.
IRO Qualifications The IRO shall. 1. assign individuals to conduct the Arrangements Review who are knowledgeable in the requirements of the Anti-Kickback Statute and the Xxxxx Law and the regulations and other guidance documents related to these statutes;
2. possess expertise in fair market valuation issues or have the ability to associate a valuation firm to assist in conducting the transactions review component of the Arrangements Review; and
3. have sufficient staff and resources to conduct the reviews required by the CIA on a timely basis.
IRO Qualifications The IRO shall.
1. assign individuals to conduct the Quarterly Claims Review who have expertise in the Medicare and state Medicaid program requirements applicable to the claims being reviewed;
2. assign individuals to design and select the Quarterly Claims Review sample who are knowledgeable about the appropriate statistical sampling techniques;
3. assign individuals to conduct the coding review portions of the Quarterly Claims Review who have a nationally recognized coding certification and who have maintained this certification (e.g., completed applicable continuing education requirements);
4. assign licensed nurses or physicians with relevant education, training and specialized expertise (or other licensed health care professional acting within their scope of practice and specialized expertise) to make the medical necessity determinations required by the Quarterly Claims Review; and
5. have sufficient staff and resources to conduct the reviews required by the IA on a timely basis.
IRO Qualifications The IRO shall. 1. assign individuals to conduct the Claims Review who have expertise in the Medicare, state Medicaid, and TRICARE program requirements applicable to the claims being reviewed;
2. assign individuals to design and select the Claims Review sample who are knowledgeable about the appropriate statistical sampling techniques;
3. assign individuals to conduct the coding review portions of the Claims Review who have a nationally recognized coding certification and who have maintained this certification (e.g., completed applicable continuing education requirements); and
4. have sufficient staff and resources to conduct the reviews required by the CIA on a timely basis.
IRO Qualifications The IRO shall. 1. assign individuals to conduct the Claims Review and Additional Items Review who have expertise in the billing, coding, claims submission and other applicable Medicare and state Medicaid program requirements;
2. assign individuals to design and select the Claims Review sample and Additional Items Review sample who are knowledgeable about the appropriate statistical sampling techniques;
3. assign individuals to conduct the coding review portions of the Claims Review and Additional Items Review who have a nationally recognized coding certification and who have maintained this certification (e.g., completed applicable continuing education requirements); and
4. have sufficient staff and resources to conduct the reviews required by the CIA on a timely basis.
IRO Qualifications The IRO shall.
1. assign individuals to conduct the Quarterly Claims Review who have expertise in the billing, coding, claims submission and other applicable Medicare and state Medicaid program requirements;
2. assign individuals to design and select the Quarterly Claims Review sample who are knowledgeable about the appropriate statistical sampling techniques;
3. assign individuals to conduct the coding review portions of the Quarterly Claims Review who have a nationally recognized coding certification and who have maintained this certification (e.g., completed applicable continuing education requirements);
4. assign licensed nurses or physicians with relevant education, training and specialized expertise (or other licensed health care professionals acting within their scope of practice and specialized expertise) to make the medical necessity determinations required by the Quarterly Claims Review; and
5. have sufficient staff and resources to conduct the reviews required by the IA on a timely basis.
IRO Qualifications The IRO shall.
1. assign individuals to conduct the IRO Reviews who have expertise in the medical device industry and have expertise in all applicable Federal health care program and FDA requirements relating to Covered Functions, including but not limited to expertise relating to marketing and promotional activities associated with medical devices and the Federal Anti-Kickback Statute and False Claims Act;
2. assign individuals to design and select the samples for the Transactions Reviews who are knowledgeable about the appropriate statistical sampling techniques; and
3. have sufficient staff and resources to conduct the reviews required by the CIA on a timely basis.
IRO Qualifications The IRO shall assign individuals to conduct the MDS Review who have expertise in the billing, coding, reporting, and other requirements of the Medicare Prospective Payment System for skilled nursing facilities and in the general requirements of the Federal health care program(s) from which Extendicare seeks reimbursement;
IRO Qualifications The IRO shall.
1. assign individuals to conduct the IRO Reviews who have expertise in all applicable Federal health care program requirements relating to Patient Assistance Related Functions, including but not limited to the Federal Anti-Kickback Statute and False Claims Act.
2. assign or retain individuals to conduct the IRO Reviews who are knowledgeable in the requirements of the Federal Anti-Kickback Statute and the regulations and other guidance documents relating to the statute, Advisory Opinion 10- 07, and guidance documents from the OIG relating to patient assistance programs (including those referenced in Section III.C of the IA), including individuals with the expertise and qualifications necessary to perform the legal analysis required by Section D.2.b.iv of Appendix B and to serve as Legal Reviewer(s) (as defined in Section III.G.3 of the IA); and
3. have sufficient staff and resources to conduct the reviews required by the IA on a timely basis.
IRO Qualifications The IRO shall. 1. assign individuals to conduct the Claims Review who have expertise in the billing, coding, reporting, and other requirements of submitting claims for power wheelchairs and accessories and in the general requirements of the Federal health care program(s) from which Orbit seeks reimbursement;
2. assign individuals to design and select the Claims Review sample who are knowledgeable about the appropriate statistical sampling techniques;
3. assign individuals to conduct the coding review portions of the Claims Review who have a nationally recognized coding certification and who have requirements); and
4. have sufficient staff and resources to conduct the reviews required by the CIA on a timely basis.
