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 reviewed shall be comprised of five strata (Strata) as follows: 15 Basic Life Support Emergency Paid Claims, 30 Basic Life Support Non-Emergency Paid Claims; 15 Advanced Life Support Emergency Paid Claims, 30 Advanced Life Support Non-Emergency Paid Claims, and 10 other Paid Claims. Each Strata shall be reviewed separately. The Paid Claims shall be reviewed based on the supporting documentation available at Liberty’s office or under Liberty’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 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.

Claims Review Sample. The IRO shall randomly select and review a sample of 100 130 Paid Claims (Claims Review Sample). The Paid Claims reviewed shall be comprised of five strata (Strata) as follows: 15 30 Basic Life Support Emergency Paid Claims, 30 50 Basic Life Support Non-Emergency Paid Claims; 15 30 Advanced Life Support Emergency Paid Claims, 30 15 Advanced Life Support Non-Emergency Paid Claims, and 10 other Paid 5 Specialty Care Transport Claims. Each Strata shall be reviewed separately. The Paid Claims shall be reviewed based on the supporting documentation available at LibertyMedstar’s office or under LibertyMedstar’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 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.