Claims Review Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Claims Review Sample). The Paid Claims shall be reviewed based on the supporting documentation available at Progenity’s office or under Progenity’s control and applicable Medicare and state Medicaid program requirements to determine whether the medical necessity of the items and services furnished was appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim.
Claims Review Sample. The IRO shall randomly select and review a sample of 30 Patient Stays in the Population at each Subject Facility (each selection of Patient Stays at a Subject Facility shall be referred to as a “Claims Review Sample”). The IRO shall review the Patient Stay and all Paid Claims associated with each selected Patient Stay. The Patient Stay and associated Paid Claims shall be reviewed based on the supporting documentation available at Sava’s office or under Sava’s control, and applicable Medicare program requirements and practice guidelines endorsed by the American Physical Therapy Association, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association to determine whether the items and services furnished were (a) medically necessary and reasonable,
Claims Review Sample. The IRO shall randomly select and review a sample of 50 Paid Claims (Claims Review Sample) for each of the Subject Facilities. The Paid Claims shall be reviewed based on the supporting documentation available at UHS’s or the Subject Facility’s office or under UHS’s control and applicable Medicare program, a state Medicaid program, or the TRICARE program requirements to determine whether the items and services furnished were medically necessary, appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim.
Claims Review Sample. The IRO shall select a random sample of 100 Medicare Paid Claims and a random sample of 100 Medicaid Paid Claims (Claims Review Sample). The IRO shall review the Paid Claims based on Practitioner’s documentation and the applicable Medicare and Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed.
Claims Review Sample. Prior to the end of each Reporting Period, Apria shall furnish to the IRO a list of the top 50 Apria locations based upon amounts received for Paid Claims together with the amounts received for Paid Claims by each of these locations during the Reporting Period (Apria Locations). The IRO shall randomly select four of these Apria Locations (Selected Apria Locations). The IRO shall randomly select and review a sample of 50 Paid Claims from each of the four Selected Apria Locations. Each sample of 50 Paid Claims from a Selected Apria Location shall be referred to as a Claims Review Sample for purposes of this Appendix. The Paid Claims for each Claims Review Sample shall be reviewed based on the supporting documentation available at Apria or under Apria’s control and applicable Medicare and state Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim.
Claims Review Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Claims Review Sample). The Paid Claims shall be reviewed based on the supporting documentation available at Lincare’s office or under Lincare’s control and applicable Medicare and state Medicaid program requirements and, in the case of managed care plans, applicable contractual requirements, to determine whether the items and services furnished were medically necessary and appropriately documented, whether the claim was correctly coded, submitted, and reimbursed, and whether the appropriate coinsurance, copayment, and deductible amount was properly charged and collected from the applicable program beneficiary. For any Paid Claim for which a coinsurance, copayment, or deductible amount was reduced or waived, the IRO shall determine whether such reduction or waiver was made and documented in compliance with the requirements of the Anti-Kickback Statute, the beneficiary inducement prohibitions of the Civil Monetary Penalties Law (CMPL) and Lincare’s policies and procedures. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that may have resulted in the 1 For purposes of this Appendix B, all references to “Medicare and state Medicaid programs” shall include Medicare and state Medicaid managed care programs. identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim.
Claims Review Sample. Prior to the end of each Reporting Period, CHN shall furnish to the IRO a list that identifies the top five CHN hospitals based upon amounts received for Paid Claims together with the amounts received for Paid Claims by each of these CHN hospitals during the Reporting Period. The IRO shall randomly select two of these hospitals (each a Selected CHN Hospital). For each of the Selected CHN Hospitals, the IRO shall select a random sample of 100 Paid Claims (each a Claims Review Sample). The IRO shall review the Paid Claims based on CHN’s documentation and the applicable Medicare program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed.
Claims Review Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Claims Review Sample) at each Selected Facility. The Paid Claims shall be reviewed based on the supporting documentation available at Prime’s office or under Prime’s control to determine whether the inpatient admission and length of stay were medically necessary and appropriate under the applicable Medicare program requirements. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that resulted in the identified Overpayment. The IRO shall provide its observations and recommendations on suggested improvements to the relevant system(s) and the process(es).
Claims Review Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Claims Review Sample). The Paid Claims shall be reviewed based on the supporting documentation available at Arc’s office or under Arc’s control and applicable Alaska Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the Paid Claim. In connection with its review of the Claims Review Sample, the IRO shall also review Arc’s billing system (currently, the Medi-Track System) to determine whether Arc has a process for accurately tracking and reporting voided and adjusted claims, and provide its observations and recommendations on suggested improvements (if any).
Claims Review Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Claims Review Sample) from the Population at each Review Location selected for review. The Paid Claims shall be reviewed based on the supporting documentation available at Xxxxxxxxxx-Xxxxxxx Xxxxxx’x office or under Xxxxxxxxxx- Xxxxxxx Xxxxxx’x control and applicable Medicare and state Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. For each claim in the Claims Review Sample that resulted in an Overpayment, the IRO shall review the system(s) and process(es) that generated the claim and identify any problems or weaknesses that may have resulted in the identified Overpayments. The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the claim. OIG, in its sole discretion, may refer the findings of the Claims Review Sample (and any related work papers) received from Xxxxxxxxxx-Xxxxxxx Xxxxxx to the appropriate Federal health care program payor (e.g., Medicare contractor) for appropriate follow-up by that payor.
