Common use of Source of Data Clause in Contracts

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation and other information sources relied upon on by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review Review‌‌ (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation and other information sources relied upon on by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title title‌‌‌ and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation and other information sources relied upon on by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).‌‌‌‌

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).‌‌‌‌‌

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician or other practitioner orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims in the Claims Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician ordersorders (including drug prescriptions), certificates state pharmacy laws or regulations regarding the dispensing of medical necessity, requisition formsprescription drugs, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation and other information sources relied upon on by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).‌‌‌‌‌

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates including drug prescriptioins), State pharmancy laws or regulations regarding the dispensing and handling of medical necessityprescription drugs, requisition forms, any applicable local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Inpatient Medical Necessity Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier‌‌‌ or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, including drug prescriptions), State pharmacy laws or regulations regarding the dispensing and handling of prescription drugs, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, physician schedules or other documentation of physician supervision, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, necessity,‌‌‌ requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor or state Medicaid carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims MDS Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and and‌‌‌ policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), Medicaid MCO other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or Universal Health Services, Inc. CIA - Appendix B bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual Medicaid or TRICARE manuals or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical recordselectronic and hard copy prescriptions, physician orders, certificates of medical necessity, requisition forms, local medical review policies CMS program memoranda (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual and/or State Medicaid manuals or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives); and applicable practice guidelines of the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology.‌‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation and other information sources relied upon on by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual Medicaid program manuals or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims MDS Review (e.g., medical medical‌‌‌ records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, and (2) the specific documentation relied upon upon‌‌ by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).‌

Source of Data. A description of (1) the process used to identify claims in the Physician Services Population or the Laboratory Services Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, electronic or hard copy prescription local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor or state Medicaid program manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the Claims Review IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1I) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g.�, medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other state Medicaid program policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician or other practitioner orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation and other information sources relied upon on by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical medical‌‌‌ necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and and‌‌‌ issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Inpatient Medical Necessity Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation and other information sources relied upon on by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates or letters of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), Medicaid regulations or other policies, regulations, or directives).‌‌‌

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).

Source of Data. A description of (1) the process used to identify claims Paid Claims in the Population, Population and (2) the specific documentation and other information sources relied upon on by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title title‌‌‌ and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).‌‌

Source of Data. A description of (1) the process used to identify claims in the PopulationPopulations, and (2) the specific documentation relied upon by the IRO when performing the Quarterly Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare contractor carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).‌‌‌directives).