Selection of Period for Review

8.4.3.1 - Selection of Period for Review (Rev. 906; Issued: 09-26-19; Effective: 01-02-19; Implementation: 01-02-19) Following selection of the provider or supplier, the contractor in conjunction with a statistical expert shall determine the time period and the number of days, weeks, months, or years for which sampling units will be reviewed. For RACs and SMRC, CMS will approve the time period. The target universe shall be selected based on these criteria. The scope of the review is determined by considering several factors that include, but are not limited to: • How long the pattern of sustained or high level of payment error is believed to have existed, • The volume of claims that are involved, • The length of time that a national coverage decision or local coverage determination has been in effect, • The extent of prepayment review already conducted or currently being conducted, • The dollar value of the claims that are involved relative to the cost of the sample, • The applicable time periods for reopening claims (see Pub. 100-04, chapter 34, section 10.6), • A clear specification of the specific data elements to be used for defining the date (type of date, e.g., day, month, year). As examples: If dates of service are used, specify, as needed, whether the dates are line service dates or claim service dates, the first day of the billing statement or the ending date of service, etc. If a span of dates is used, clarify the criteria used when the span overlaps the boundary of one of the other criterion date ranges. If paid dates or receipt dates are used, clarify the role of the adjusted claims. All case documentation, including the overpayment demand letter and methodology, should consistently reflect the same date range and specify the same type of date. NOTE: When sampling claims that are paid through cost report (as opposed to claims paid under a PPS reimbursement methodology), all claims reviewed must be drawn from within a provider’s/supplier’s defined cost reporting year. If the period under review is greater than one year, it is important to select a separate sample for each cost-reporting year.