Claims Review Samples. The IRO shall randomly select and annually review the following categories of Paid Claims: (1) a sample of 25 Paid Claims submitted for items and services provided at clinics owned by Xxxxx Xxxx, D.D.S.; (2) a sample of 25 Paid Claims submitted for items and services provided at clinics owned by Xxxxx Xxxxxxxxxx, D.D.S.; (3) a sample of 25 Paid Claims submitted for items and services provided at clinics owned by Xxxxxxxx Xxxxxxx, D.D.S.; (4) a sample of 25 Paid Claims submitted for items and services provided at clinics owned by Xxxxxxx Xxxxxxx, D.D.S.;
Claims Review Samples. For the first Reporting Period of the CIA, the IRO shall select a random sample of 100 Sierra Vista Medicare Paid Claims and a random sample of 100 Twin Cities Medicare Paid Claims (Claims Review Samples). The IRO shall review the Paid Claims based on Sierra Vista’s or Twin Cities’ documentation (as applicable) 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. For the second Reporting Period of the CIA, the IRO shall select a random sample of 100 Sierra Vista Medicaid Managed Care Paid Claims and a random sample of 100 Twin Cities Medicaid Managed Care Paid Claims. The IRO shall review the Paid Claims based on Sierra Vista’s or Twin Cities’ documentation (as applicable) and the applicable Medicaid Managed Care Organization 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 the remaining three Reporting Periods, at least 30 days prior to the end of the applicable Reporting Period, the OIG shall select whether the Claims Review Samples shall consist of Medicare Paid Claims or Medicaid Managed Care Paid Claims and shall notify Sierra Visit and Twin Cities of its selection.
Claims Review Samples
