Common use of Claims Review Sample Clause in Contracts

Claims Review Sample. The IRO shall randomly select and review a sample of 50 Paid Claims at each Claims Review Facility (each review at a Claims Review Facility shall be referred to as a “Claims Review Sample”). The Paid Claims in each Claims Review Sample shall be reviewed based on the supporting documentation available at Vibra’s office, any of the Claims Review Facilities, or under Vibra’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 Paid Claim in each Claims Review Sample was correctly coded, submitted, and reimbursed pursuant to Medicare LTCH and IRF coverage criteria, as applicable. For each Paid Claim in any Claims Review Sample that results 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 Paid Claim. OIG, in its sole discretion, may refer the findings of any Claims Review Sample (and any related work papers) received from Vibra to the appropriate Federal health care program payor (e.g., Medicare contractor) for appropriate follow-up by that payor.

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 at from each of the four Selected Apria Locations. Each sample of 50 Paid Claims Review Facility (each review at from a Claims Review Facility Selected Apria Location shall be referred to as a “Claims Review Sample”)Sample for purposes of this Appendix. The Paid Claims in for each Claims Review Sample shall be reviewed based on the supporting documentation available at Vibra’s office, any of the Claims Review Facilities, Apria or under VibraApria’s control and applicable Medicare and state Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented documented, and whether the Paid Claim in each Claims Review Sample claim was correctly coded, submitted, and reimbursed pursuant to Medicare LTCH and IRF coverage criteria, as applicablereimbursed. For each Paid Claim in any the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the claim 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. OIG, in its sole discretion, may refer the findings of any Claims Review Sample (and any related work papers) received from Vibra to the appropriate Federal health care program payor (e.g., Medicare contractor) for appropriate follow-up by that payor.

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 at from each of the four Selected Apria Locations. Each sample of 50 Paid Claims Review Facility (each review at from a Claims Review Facility Selected Apria Location shall be referred to as a “Claims Review Sample”)Sample for purposes of this Appendix. The Paid Claims in for each Claims Review Sample shall be reviewed based on the supporting documentation available at Vibra’s office, any of the Claims Review Facilities, Apria or under VibraApria’s control and applicable Medicare and state Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented documented, and whether the Paid Claim in each Claims Review Sample claim was correctly coded, submitted, and reimbursed pursuant to Medicare LTCH and IRF coverage criteria, as applicablereimbursed. For each Paid Claim in any the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the claim 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. OIG, in its sole discretion, may refer the findings of any Claims Review Sample (and any related work papers) received from Vibra to the appropriate Federal health care program payor (e.g., Medicare contractor) for appropriate follow-up by that payor.Apria - Corporate Integrity Agreement Appendix B