Claims Review definition

Claims Review. The IRO shall review claims submitted by Essex and reimbursed by the Medicare program, to determine whether the items and services furnished were (a) medically necessary and reasonable, (b) appropriate and sufficient to meet the needs of a patient in the assigned Case-Mix Groups, (c) appropriately documented, and (d) whether the associated Paid Claims were correctly coded, submitted, and reimbursed (Claims Review) and shall prepare a Claims Review Report, as outlined in Appendix B to this CIA, which is incorporated by reference.”

Split View

AI-Powered Contracts

Draft, Review & Redline at the Speed of AI

Get StartedSchedule a Demo

Claims Review means the review of claims by AAR to determine liability and amount of payment for various services.

Claims Review means the assessment by or on behalf of the health plan of the health care services rendered and charges made, followed by either the authorization of payment or nonpayment.

Examples of Claims Review in a sentence

• The IRO shall prepare a Claims Review Report as described in this Appendix for each Claims Review performed.

• The names and credentials of the individuals who: (1) designed the statistical sampling procedures and the review methodology utilized for the Claims Review and (2) performed the Claims Review.

• A narrative description of how the Claims Review was conducted and what was evaluated.

• The IRO shall perform the Claims Review annually to cover each of the five Reporting Periods.

• A clear statement of the objective intended to be achieved by the Claims Review.

• In addition, the IRO shall include a narrative in the Claims Review Report describing the process by which the Supplemental Materials were accepted and the IRO’s reasons for accepting the Supplemental Materials.

• The Population shall be defined as all Paid Claims during the 12-month period covered by the Claims Review.

• The IRO shall prepare a Claims Review Report for each Quarterly Claims Review performed (Quarterly Claims Review Report).

• Each Quarterly Claims Review Report shall include the information specified in Appendix B to this IA.

• The following information shall be included in the Claims Review Report for each Discovery Sample and Full Sample (if applicable).

More Definitions of Claims Review

Claims Review. Any Participant or beneficiary who has been denied a benefit, or feels aggrieved by any other action of the Plan Administrator or the Trustee, shall be entitled, upon request to the Plan Administrator and if he has not already done so, to receive a written notice of such action, together with a full and clear statement of the reasons for the action. If the claimant wishes further consideration of his position, he may file with the Plan Administrator a written request for a hearing, together with a written statement of the claimant's position, which shall be filed with the Plan Administrator no later than sixty (60) days after receipt of the written notification provided for above or in section 13.

Claims Review. The IRO shall review claims submitted by FHS and reimbursed by the Medicare program, to determine whether the items and services furnished were medically necessary and appropriately documented and whether the claims were correctly coded, submitted and reimbursed (Claims Review) and shall prepare a Claims Review Report, as outlined in Appendix C to this CIA, which is incorporated by reference.