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). The Paid Claims shall be reviewed based on the supporting documentation available at Arc’s office or under Arc’s control and applicable Alaska Medicaid program requirements to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claim was correctly coded, submitted, and reimbursed. 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 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. In connection with its review of the Claims Review Sample, the IRO shall also review Arc’s billing system (currently, the Medi-Track System) to determine whether Arc has a process for accurately tracking and reporting voided and adjusted claims, and provide its observations and recommendations on suggested improvements (if any).