Common use of Quantitative Results Clause in Contracts

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCS. iv. Total dollar amount of all Overpayments in the sample. v. Total dollar amount of Paid Claims included in the sample and the net Overpayment associated with the sample. vi. Error Rate in the sample. vii. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submitted, procedure code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary and appropriate.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the coding of the Paid Claims submitted by GSCS (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the paymentcoding and in which such difference resulted in an Overpayment. ii. Total number and percentage of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure Paid Claim was not medically necessary or appropriateappropriately documented and in which such documentation errors resulted in an Overpayment. iii. Total number and percentage of instances in which the IRO determined that a Paid Claim Submitted differed from the Correct Claim was for items or services that were not medically necessary and in which such difference resulted in an Overpayment to GSCSOverpayment. iv. Total dollar amount of all Overpayments in the sampleClaims Review Sample. v. Total dollar amount of Paid Claims included in the sample and the net Overpayment associated with the sampleClaims Review Sample. vi. Error Rate in the sampleClaims Review Sample. The Error Rate shall be calculated by dividing the Overpayment in the Claims Review Sample by the total dollar amount associated with the Paid Claims in the Claims Review Sample. vii. An estimate of the actual Overpayment in the Population at the mean point estimate. viii. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submittedsubmitted (e.g., procedure DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary and appropriate.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS Ocean Dental (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCSOcean Dental. iviii. Total dollar amount of all Overpayments in the sampleDiscovery Sample and the Full Sample (if applicable). v. iv. Total dollar amount of Paid Claims included in the sample Discovery Sample and the Full Sample and the net Overpayment associated with the sampleDiscovery Sample and the Full Sample. vi. v. Error Rate in the sampleDiscovery Sample and the Full Sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submittedsubmitted (e.g., procedure DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount. vii. If a Full Sample is performed, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary methodology used by the IRO to estimate the actual Overpayment in the Population and appropriatethe amount of such Overpayment.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS Tri- County (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCSTri- County. iviii. Total dollar amount of all Overpayments in the sampleDiscovery Sample and the Full Sample (if applicable). v. iv. Total dollar amount of Paid Claims included in the sample Discovery Sample and the Full Sample and the net Overpayment associated with the sampleDiscovery Sample and the Full Sample. vi. v. Error Rate in the sampleDiscovery Sample and the Full Sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submittedsubmitted (e.g., procedure DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount. vii. If a Full Sample is performed, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary methodology used by the IRO to estimate the actual Overpayment in the Population and appropriatethe amount of such Overpayment.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS ▇▇▇▇▇▇▇▇▇▇ was improperly coded, submitted, reimbursed, or was not medically necessary or appropriate (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCS▇▇▇▇▇▇▇▇▇▇. iviii. Total dollar amount of all Overpayments in the sample. v. iv. Total dollar amount of Paid Claims included in the sample and the net Overpayment associated with the sample. vi. v. Error Rate in the sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submitted, procedure code reimbursed, type of cardiac procedure provided, whether the procedure was medically necessary and appropriate, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary and appropriate.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS ▇▇▇▇▇ was improperly coded, submitted, reimbursed, or was not medically necessary or appropriate (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCS▇▇▇▇▇. iviii. Total dollar amount of all Overpayments in the sample. v. iv. Total dollar amount of Paid Claims included in the sample and the net Overpayment associated with the sample. vi. v. Error Rate in the sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submitted, procedure code reimbursed, type of cardiac procedure provided, whether the procedure was medically necessary and appropriate, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary and appropriate.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS La Fuente (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCSLa Fuente. iviii. Total dollar amount of all Overpayments in the sampleDiscovery Sample and the Full Sample (if applicable). v. iv. Total dollar amount of Paid Claims included in the sample Discovery Sample and the Full Sample and the net Overpayment associated with the sampleDiscovery Sample and the Full Sample. vi. v. Error Rate in the sampleDiscovery Sample and the Full Sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submittedsubmitted (e.g., procedure DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount. vii. If a Full Sample is performed, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary methodology used by the IRO to estimate the actual Overpayment in the Population and appropriatethe amount of such Overpayment.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS Amedisys (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCSAmedisys. iviii. Total dollar amount of all Overpayments in the sample.Discovery Sample and the Full Sample (if applicable). Amedisys, Inc. and Amedisys Holding, LLC Corporate Integrity Agreement Appendix B v. iv. Total dollar amount of Paid Claims included in the sample Discovery Sample and the Full Sample and the net Overpayment associated with the sampleDiscovery Sample and the Full Sample. vi. v. Error Rate in the sampleDiscovery Sample and the Full Sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submittedsubmitted (e.g., procedure DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount. vii. If a Full Sample is performed, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary methodology used by the IRO to estimate the actual Overpayment in the Population and appropriatethe amount of such Overpayment.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS Baptist (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCSBaptist. iviii. Total dollar amount of all Overpayments in the sampleDiscovery Sample and the Full Sample (if applicable). v. iv. Total dollar amount of Paid Claims included in the sample Discovery Sample and the Full Sample and the net Overpayment associated with the sampleDiscovery Sample and the Full Sample. vi. v. Error Rate in the sampleDiscovery Sample and the Full Sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submittedsubmitted (e.g., procedure DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount. vii. If a Full Sample is performed, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary methodology used by the IRO to estimate the actual Overpayment in the Population and appropriatethe amount of such Overpayment.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS First Call (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCSFirst Call. iviii. Total dollar amount of all Overpayments in the sampleDiscovery Sample and the Full Sample (if applicable). v. iv. Total dollar amount of Paid Claims included in the sample Discovery Sample and the Full Sample and the net Overpayment associated with the sampleDiscovery Sample and the Full Sample. vi. v. Error Rate in the sampleDiscovery Sample and the Full Sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submittedsubmitted (e.g., procedure DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount. vii. If a Full Sample is performed, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary methodology used by the IRO to estimate the actual Overpayment in the Population and appropriatethe amount of such Overpayment.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS Southern States (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCSSouthern States. iviii. Total dollar amount of all Overpayments in the sampleDiscovery Sample and the Full Sample (if applicable). v. iv. Total dollar amount of Paid Claims included in the sample Discovery Sample and the Full Sample and the net Overpayment associated with the sampleDiscovery Sample and the Full Sample. vi. v. Error Rate in the sampleDiscovery Sample and the Full Sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submittedsubmitted (e.g., procedure DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount. vii. If a Full Sample is performed, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary methodology used by the IRO to estimate the actual Overpayment in the Population and appropriatethe amount of such Overpayment.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS Home Bound (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCSHome Bound. iviii. Total dollar amount of all Overpayments in the sampleDiscovery Sample and the Full Sample (if applicable). v. iv. Total dollar amount of Paid Claims included in the sample Discovery Sample and the Full Sample and the net Overpayment associated with the sampleDiscovery Sample and the Full Sample. vi. v. Error Rate in the sampleDiscovery Sample and the Full Sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submittedsubmitted (e.g., procedure DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount. vii. If a Full Sample is performed, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary methodology used by the IRO to estimate the actual Overpayment in the Population and appropriatethe amount of such Overpayment.

Quantitative Results. i. Total number and percentage of instances in which the IRO determined that the Paid Claims submitted by GSCS PALMS (Claim Submitted) differed from what should have been the correct claim (Correct Claim), regardless of the effect on the payment. ii. Total number of instances in which the IRO determined that a Cardiac Diagnostic Test or Cardiac Procedure was not medically necessary or appropriate. iii. Total number and percentage of instances in which the Claim Submitted differed from the Correct Claim and in which such difference resulted in an Overpayment to GSCSPALMS. iviii. Total dollar amount of all Overpayments in the sampleDiscovery Sample and the Full Sample (if applicable). v. iv. Total dollar amount of Paid Claims included in the sample Discovery Sample and the Full Sample and the net Overpayment associated with the sampleDiscovery Sample and the Full Sample. vi. v. Error Rate in the sampleDiscovery Sample and the Full Sample. viivi. A spreadsheet of the Quarterly Claims Review Sample results that includes the following information for each Paid Claim: Federal health care program billed, beneficiary health insurance claim number, date of service, procedure code submittedsubmitted (e.g., procedure DRG, CPT code, etc.), code reimbursed, allowed amount reimbursed by payor, correct procedure code (as determined by the IRO), correct allowed amount (as determined by the IRO), dollar difference between allowed amount reimbursed by payor and the correct allowed amount. vii. If a Full Sample is performed, whether the Cardiac Procedure or Cardiac Diagnostic Test was medically necessary methodology used by the IRO to estimate the actual Overpayment in the Population and appropriatethe amount of such Overpayment.