Common use of Full Sample Clause in Contracts

Full Sample. If the Discovery Sample indicates that the Error Rate is 5% or greater, the IRO shall select an additional sample of Paid Claims (Full Sample) using commonly accepted sampling methods. The Paid Claims selected for the Full Sample shall be reviewed based on supporting documentation available at CareMed or under CareMed’s control (including but not limited to, an electronic or hard copy of the prescription, proof of delivery of the prescription, and any documentation relating to prior authorizations required by the payor for the prescription), and applicable billing and coding regulations and guidance, and Part D plan payment provisions to determine whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim reviewed, the IRO should verify that CareMed maintained documentation of (1) the prescription or order for the drug, item, or supply dispensed; (2) the delivery of the drug, item, or supply; and (3) any required preauthorization. For purposes of calculating the size of the Full Sample, the Discovery Sample may serve as the probe sample, if statistically appropriate. Additionally, the IRO may use the Paid Claims sampled as part of the Discovery Sample, and the corresponding findings for those Paid Claims, as part of its Full Sample, if: (1) statistically appropriate and (2) the IRO selects the Full Sample Paid Claims using the seed number generated by the Discovery Sample. The findings of the Full Sample shall be used by the IRO to estimate the actual Overpayment in the Population with a 90% confidence level and with a maximum relative precision of 25% of the point estimate. OIG, in its sole discretion, may refer the findings of the Full Sample (and any related workpapers) received from CareMed to the appropriate Federal health care program payor (e.g., Medicare contractor), for appropriate follow-up by that payor.

Full Sample. If the Discovery Sample indicates that the Error Rate is 5% or greater, the IRO shall select an additional sample of Paid Claims (Full Sample) using commonly accepted sampling methods. The Paid Claims selected for the Full Sample shall be reviewed based on supporting documentation available at CareMed or under CareMed’s control (including but not limited to, an electronic or hard copy of the prescription, proof of delivery of the prescription, and any documentation relating to prior authorizations required by the payor for the prescription), and applicable billing and coding regulations and guidance, and Part D plan payment provisions to determine whether the claim was correctly coded, submitted, and reimbursed. For each Paid Claim reviewed, the IRO should verify that CareMed maintained documentation of (1) the prescription or order for the drug, item, or supply dispensed; (2) the delivery of the drug, item, or supply; and (3) any required preauthorization. For purposes of calculating the Corporate Integrity Agreement between the Office of Inspector General and Sorkin’s Rx Ltd. d/b/a CareMed Pharmaceutical Services size of the Full Sample, the Discovery Sample may serve as the probe sample, if statistically appropriate. Additionally, the IRO may use the Paid Claims sampled as part of the Discovery Sample, and the corresponding findings for those Paid Claims, as part of its Full Sample, if: (1) statistically appropriate and (2) the IRO selects the Full Sample Paid Claims using the seed number generated by the Discovery Sample. The findings of the Full Sample shall be used by the IRO to estimate the actual Overpayment in the Population with a 90% confidence level and with a maximum relative precision of 25% of the point estimate. OIG, in its sole discretion, may refer the findings of the Full Sample (and any related workpapers) received from CareMed to the appropriate Federal health care program payor (e.g., Medicare contractor), for appropriate follow-up by that payor.