Common use of Claims Review Sample Clause in Contracts

Claims Review Sample. The IRO shall randomly select and review a sample of 100 Paid Claims (Claims Review Sample) at each Selected Facility. The Paid Claims shall be reviewed based on the supporting documentation available at Prime’s office or under Prime’s control to determine whether the inpatient admission and length of stay were medically necessary and appropriate under the applicable Medicare program requirements. For each Paid Claim in the Claims Review Sample that results in an Overpayment, the IRO shall review the system(s) and process(es) that generated the Paid Claim and identify any problems or weaknesses that resulted in the identified Overpayment. The IRO shall provide its observations and recommendations on suggested improvements to the relevant system(s) and the process(es).‌