Claims Review definition

Claims Review. The IRO shall review claims submitted by LCCA 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.”
Sample 1
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.
Sample 1Sample 2
Claims Review means the review of claims by AAR to determine liability and amount of payment for various services.
Sample 1Sample 2

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.

  • 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.

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

  • 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.

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

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

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

  • A description of the specific documentation relied upon by the IRO when performing the 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 carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).

  • The IRO must perform the Claims Review in a professionally independent and objective fashion, as defined in the most recent Government Auditing Standards issued by the United States Government Accountability Office.


More Definitions of Claims Review

Claims Review. The IRO shall review claims submitted by Signature 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.”
Sample 1
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 13.16. The Plan Administrator shall then schedule and conduct a full and fair hearing of the issue within the next thirty (30) days. The decision following such hearing shall be made within thirty (30) days, shall be communicated in writing to the claimant, and shall be the final disposition of the matter. SECTION FOURTEEN
Sample 1

Related to Claims Review

  • independent review committee means the independent review committee of the investment fund established under National Instrument 81-107 Independent Review Committee for Investment Funds;

  • Grievance Committee means the Grievance Committee of the Bar.

  • Appeal Committee means the appeal committee established by the Council in terms of section 12(3)(a);

  • Peer review committee means one or more persons acting in a peer review capacity who also serve as an officer, director, trustee, agent, or member of any of the following:

  • Review Committee or “Committee” means a committee established pursuant to rule Chapter 67-60, F.A.C.

  • Review Panel means the panel, if any, appointed pursuant toRule 710 to review a completed Investigation Report and to determine whether a reasonable basis exists for finding a violation of the Rules and authorizing the issuance of a notice of charge pursuant to Rule 706.

  • Claims Procedure Order means the Order under the CCAA establishing a claims procedure in respect of the Applicant, as same may be further amended, restated or varied from time to time.

  • Claims Bar Date means the applicable bar date by which Proofs of Claim must be Filed, as established by: (a) the Bar Date Order; (b) a Final Order of the Bankruptcy Court; or (c) the Plan.

  • Claims Process means the process for Settlement Class Members’ submission of Claims, as described in Section III.

  • Claims Administrator means the firm proposed by Class Counsel and appointed by the Courts to administer the Settlement Amount in accordance with the provisions of this Settlement Agreement and the Distribution Protocol, and any employees of such firm.

  • Utilization review plan or "plan" means a written procedure for performing review.

  • Investigation Committee means the Investigation Committee appointed by the Board under Regulation 5 of these Regulations;

  • District Evaluation Advisory Committee means a group created to oversee and guide the planning and implementation of the Board of Education's evaluation policies and procedures as set forth in N.J.A.C. 6A:10-2.3.

  • Peer review means evaluation of professional services rendered by a professional practitioner.

  • Appeals Tribunal or “AT” means the Body responsible for hearing and determining appeals set out in section 9;

  • Ethics Committee means an independent body established in a Member State in accordance with the law of that Member State and empowered to give opinions for the purposes of this Regulation, taking into account the views of laypersons, in particular patients or patients' organisations;

  • IEP Team means a group of individuals described in Wis. Stat. § 115.78 that is responsible for evaluating the child to determine the child’s eligibility or continued eligibility for special education and related services and the educational needs of the child; developing, reviewing, or revising an IEP for the child; and determining the special education placement for the child.

  • Administrative Review means any decision making process of the director requested by a party aggrieved with an action taken under these rules except the hearing process described in OAR 436-001.

  • Appeals Panel means a panel appointed by the Chief Compliance Officer pursuant to Rule 620.

  • Evaluation Team means the team appointed by the City; “Information Meeting” has the meaning set out in section 2.2;

  • Review Criteria has the meaning assigned to that term in Section 12.02(b)(i).