Common use of Systems Review Clause in Contracts

Systems Review. If CareMed’s Discovery Sample identifies an Error Rate of 5% or greater, CareMed’s IRO shall also conduct a Systems Review. The Systems Review shall consist of the following: a. a review of CareMed’s billing systems and processes relating to claims submitted to Federal health care programs (including, but not limited to, the operation of the billing system, the process by which CareMed prepares and submits claims for drugs that require pre-dispensing authorization from health plans, the process by which CareMed maintains documentation of prescriptions and orders and of the delivery of all drugs and supplies dispensed, safeguards to ensure proper claims submission and billing; and procedures to identify and correct inaccurate billing); b. for each claim in the Discovery Sample and Full Sample that resulted 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 claim.