Chart Review Sample Sample Clauses

Chart Review Sample. The IRO shall randomly select a sample of 100 Risk Adjusted Members (Chart Review Sample) from the Population. The Diagnosis Data and the Medical Records associated with the Chart Review Sample and available at BMG’s office or under BMG’s control shall be reviewed to determine whether the Diagnosis‌ Data is supported by the Medical Records and correctly documented and coded, e.g., in accordance with ICD-9/10 coding guidelines.‌ a. The OIG may limit the Population to Risk Adjusted Members with specific HCCs or to Risk Adjusted Members who received care or treatment by particular BMG physician(s), or using other factors determined by the OIG in its discretion. In the event that OIG exercises its discretion to limit the Population, OIG shall notify BMG at least 60 days prior to the end of the Reporting Period of any information needed from BMG in order for the OIG to identify the Population. The OIG shall notify BMG and its IRO of the subset of the Population to be reviewed at least 30 days prior to the end of the Reporting Period.‌ b. For any Risk Adjusting Diagnosis in the Chart Review Sample that is not supported by the Medical Record or documented and coded correctly (collectively, Unsupported Diagnosis), the IRO shall identify any correction to the Diagnosis Data and the basis for the IRO’s determination that the Risk Adjusting Diagnosis was not appropriately documented and coded or supported by the Medical Record, review the controls for ensuring that each Risk Adjusting Diagnosis submitted to a Medicare Advantage plan is appropriately documented and coded, review the system(s) and process(es) (e.g., improper use of an electronic problem list) that generated the Unsupported Diagnosis and identify any problems or weaknesses that may have resulted in the Unsupported Diagnosis. The IRO shall provide its observations and recommendations on suggested improvements to the system(s), process(es) and controls relating to the Unsupported Diagnosis.‌