Common use of Eligibility Review Clause in Contracts

Eligibility Review. The IRO shall select a Beneficiary Sample. For each Medicare beneficiary in the Beneficiary Sample, the IRO shall randomly select a Claim Period to be reviewed (Selected Claim Period). The IRO shall review the medical records of each Medicare beneficiary in the Beneficiary Sample based on the supporting documentation available at VITAS's offices or under VITAS's control and applicable billing and coding regulations and guidance to determine whether the beneficiary was eligible for hospice services for the Selected Claim Period. For any beneficiary in the Beneficiary Sample that results in a determination by the IRO that the beneficiary was not eligible for the hospice benefit during the Selected Claim Period, the IRO shall review all claims for hospice services billed by VITAS for that beneficiary to determine whether the beneficiary was eligible for hospice services. The IRO shall submit a supplemental report no later than 90 days after the IRO completes its report. VITAS shall refund any Overpayments identified as a result of this additional review and documentation of the refund of any identified Overpayments shall be made available to OIG upon request. Additionally, the IRO shall perform a review of the system(s) and process(es) that resulted in VITAS's erroneous determination that the beneficiary was eligible for the hospice benefit, to identify any problems or weaknesses that may have resulted in the identified error(s). The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) for determining eligibility for the hospice benefit.

Eligibility Review. The IRO shall select a Beneficiary Sample. For each Medicare beneficiary in the Beneficiary Sample, the IRO shall randomly select a Claim Period to be reviewed (Selected Claim Period). The IRO shall review the medical records of each Medicare beneficiary in the Beneficiary Sample based on the supporting documentation available at VITAS's ’s offices or under VITAS's ’s control and applicable billing and coding regulations and guidance to determine whether the beneficiary was eligible for hospice services for the Selected Claim Period. For any beneficiary in the Beneficiary Sample that results in a determination by the IRO that the beneficiary was not eligible for the hospice benefit during the Selected Claim Period, the IRO shall review all claims for hospice services billed by VITAS for that beneficiary to determine whether the beneficiary was eligible for hospice services. The IRO shall submit a supplemental report no later than 90 days after the IRO completes its report. VITAS shall refund any Overpayments identified as a result of this additional review and documentation of the refund of any identified Overpayments shall be made available to OIG upon request. Additionally, the IRO shall perform a review of the system(s) and process(es) that resulted in VITAS's ’s erroneous determination that the beneficiary was eligible for the hospice benefit, to identify any problems or weaknesses that may have resulted in the identified error(s). The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) for determining eligibility for the hospice benefit.