Quarterly Claims Sample Sample Clauses

Quarterly Claims Sample a. Within 15 days following the end of each three-month period during the term of the IA, the IRO shall randomly select a sample of 30 Paid Claims from the preceding three-month period (Quarterly Claims Sample). The sample must be selected through the use of OIG’s Office of Audit Services’ Statistical Sampling Software, also known as RAT-STATS, which is currently available at xxxxx://xxx.xxx.xxx/compliance/rat-stats/index.asp.‌
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Quarterly Claims Sample. Within 15 days following the end of each three-month period during the term of this IA, the IRO shall randomly select a sample of 30 Paid Claims submitted by or on behalf of Xxxxx during the preceding three-month period (Quarterly Claims Sample). The sample must be selected through the use of OIG’s Office of Audit Services’ Statistical Sampling Software, also known as RAT- STATS, which is currently available at xxxxx://xxx.xxx.xxx/compliance/rat-stats/index.asp. Xxxxx shall provide the IRO with a list of all Xxxxx’ Paid Claims for the three-month period covered by the Quarterly Claims Sample. The IRO should number each Paid Claim in the Population sequentially prior to generating the random numbers used to select the Quarterly Claims Sample. The IRO should generate 30 random numbers using RAT-STATS and then use the random numbers to identify the 30 Paid Claims in the Population that will be subject to review by the IRO. The randomly selected 30 Paid Claims will be reviewed by the IRO based on the supporting documentation available at Xxxxx’ offices or under Xxxxx’ control and applicable billing and coding regulations and guidance to determine whether each claim was correctly coded, submitted, and reimbursed. The IRO shall prepare a written report of its findings from the Quarterly Claims Sample, as described in Section B below (Quarterly Claims Review Report). The Quarterly Claims Review Report shall be submitted to the OIG within 60 days following the end of the three-month period covered by each Quarterly Claims Review.
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Quarterly Claims Sample a. Within 15 days following the end of each three-month period during the term of the IA, the IRO shall randomly select a sample of 30 Paid Claims submitted by or on behalf ofNorthwest ENT during the preceding three-month period (Quarterly Claims Sample). The sample must be selected through the use of OIG' s Office of Audit Services' Statistical Sampling Software, also known as RAT-‌ STATS, which is currently available at xxxxx://xx x.xxx.xxx/xxxxxxxxxx/xxx-xxxxx/xxxxx.xxx. Northwest ENT IA Appenaix 8
Sample 1
Quarterly Claims Sample. Within 15 days following the end of each three-month period during the term of this IA, the IRO shall randomly select a sample of 30 Paid Claims submitted by or on behalf of Xxxxx during the preceding three-month period (Quarterly Claims Sample). The sample must be selected through the use of OIG’s Office of Audit Services’ Statistical Sampling Software, also known as RAT- STATS, which is currently available at xxxxx://xxx.xxx.xxx/compliance/rat-stats/index.asp. Xxxxx shall provide the IRO with a list of all Xxxxx’s Paid Claims for the three-month period covered by the Quarterly Claims Sample. The IRO should number each Paid Claim in the Population sequentially prior to generating the random numbers used to select the Quarterly Claims Sample. The IRO should generate 30 random numbers using RAT-STATS and then use the random numbers to identify the 30 Paid Claims in the Population that will be subject to review by the IRO. The IRO shall review the randomly selected 30 Paid Claims for (1) correct coding, submission, and reimbursement, and (2) medical necessity, appropriateness of case selection, quality of procedure, execution, proper response to intraprocedural problems, accurate assessment of procedure outcome, and appropriateness of procedure management. The Paid Claims shall be reviewed based on the supporting documentation available from Anand or under Xxxxx’s control and applicable regulations and guidance, including but not limited to applicable billing and coding regulations and guidance and the established practice guidelines and generally accepted standards practice described by the American College of Cardiology, to determine (1) whether each claim was correctly coded, submitted, and reimbursed, and (2) whether each procedure was medically necessary and appropriate. The IRO shall prepare a written report of its findings from the Quarterly Claims Sample, as described in Section C below (Quarterly Claims and Cardiac Procedures Review Report). The Quarterly Claims and Cardiac Procedures Review Report shall be submitted to the OIG within 60 days following the end of the three-month period covered by each Quarterly Claims and Cardiac Procedures Review.
Sample 1
Quarterly Claims Sample a. Within 15 days following the end of each three-month period during the term of the IA, the IRO shall randomly select a sample of 30 Paid Claims submitted by or on behalf of Alaska Neurology during the preceding three-month period (Quarterly Claims Sample). The sample must be selected through the use of OIG’s Office of Audit Services’ Statistical Sampling Software, also known as RAT- STATS, which is currently available at xxxxx://xxx.xxx.xxx/compliance/rat-stats/index.asp.
Sample 1
Quarterly Claims Sample a. Within 15 days following the end of each three-month period during the term of the IA, the IRO shall randomly select a sample of 30 Paid Claims submitted by or on behalf of Xxxxxx during the preceding three-month period (Quarterly Claims Sample). The sample must be selected through the use of OIG’s Office of Audit Services’ Statistical Sampling Software, also known as RAT-‌ 1 The overpayment definition and paid claim definition should be expanded to include other Federal health care programs if claims to those payors were at issue in the underlying case or represent a significant portion of the Practitioner’s payor mix.‌ STATS, which is currently available at‌‌‌ xxxxx://xxx.xxx.xxx/compliance/rat-stats/index.asp.
Sample 1
Quarterly Claims Sample a. Within 15 days following the end of each three-month period during the term of the IA, the IRO shall randomly select a sample of 30 Paid Claims submitted by or on behalf of Xxxxx Pharmacy during the preceding three-month period (Quarterly Claims Sample). The sample must be selected through the use of OIG's Office of Audit Services' Statistical Sampling Software, also known as RAT- STATS, which is currently available at xxxxx://xxx.xxx.xxx/compliance/rat-stats/index.asp.‌‌ Xxxxxx Xxxxx Professional Pharmacy, Inc. dlbla Xxxxx Pharmacy, Gwy Xxxx, and Xxxxxx X. Xxxxxxx Integrity Agreement- Appendix B
Sample 1
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Related to Quarterly Claims Sample

  • Claims Review Population A description of the Population subject to the Claims Review.

  • Claims Review Objective A clear statement of the objective intended to be achieved by the Claims Review.

  • Liability Calculation Method Per Claim Unless subject to a fixed dollar copayment, the calculation of Member liability on claims for Out-of-Area Covered Health Care Services processed through the BlueCard Program will be based on the lower of the provider’s billed charges or the negotiated price made available to Blue Shield by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s health care provider contracts. The negotiated price made available to Blue Shield by the Host Blue may be represented by one of the following:

  • Claims Review The IRO shall perform the Claims Review annually to cover each of the five Reporting Periods. The IRO shall perform all components of each Claims Review.

  • Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Negotiated (non–BlueCard Program) Arrangements With respect to one or more Host Blues, in certain instances, instead of using the BlueCard Program, we may process your claims for covered healthcare services through Negotiated Arrangements for National Accounts. The amount you pay for covered healthcare services under this arrangement will be calculated based on the negotiated price (refer to the description of negotiated price in the BlueCard® Program section above) made available to us by the Host Blue.

  • Claims Review Report The IRO shall prepare a Claims Review Report as described in this Appendix for each Claims Review performed. The following information shall be included in the Claims Review Report for each Discovery Sample and Full Sample (if applicable).

  • Claims Payment The Reinsurer will be liable to the Company for its share of the benefits owed under the express contractual terms of the Reinsured Policies and as specified under the terms of this Agreement. The Reinsurer will not participate in any ex gratia payments made by the Company (i.e., payments the Company is not required to make under the Reinsured Policy terms.) The payment of death benefits by the Reinsurer will be in one lump sum regardless of the mode of settlement under the Reinsured Policy. Benefit payments from the Reinsurer will be due within 30 days of the claim satisfying the requirements established under this Agreement. The Reinsurer’s share of any interest payable under the terms of a Reinsured Policy or applicable law which is based on the death benefits paid by the Company, will be payable provided that the Reinsurer will not be liable for interest accruing on or after the date of the Company’s payment of benefits. The Reinsurer will make payment to the Company for each such claim. For Waiver of Premium claims, the Company will continue to pay premiums for reinsurance, except premiums for disability reinsurance. The Reinsurer will pay its proportionate share of the gross premium waived by the Company on the Reinsured Policy, including its share of the premiums for benefits that remain in effect during disability. For claims on Accelerated Benefit riders reinsured under this Agreement, the benefit amount payable by the Reinsurer will be calculated by multiplying the total accelerated death benefit rider payout by the ratio of the reinsured Net Amount at Risk, as defined in Exhibit C-1, to the face amount of the Reinsured Policy.

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