Composition of the Universe

8.4.3.2.1 - Composition of the Universe (Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23) A. Part A Claims: For providers/suppliers reimbursed through cost report, the universe of claims from which the sample is selected shall consist of fully and partially adjudicated claims obtained from the shared systems that meet the criteria in the definition of the universe. For such claims, use the service date to match findings to the cost report. For providers/suppliers reimbursed under PPS, the universe of claims from which the sample is selected will consist of all fully and partially paid claims submitted by the provider/supplier for the period under review. Sampling units with no final payment made at the time of sample selection should not be included in the sampling frame. Claims with no payment may be included in the universe from which the sampling frame is constructed and should be excluded when establishing the sampling frame. B. Part B Claims: The universe shall consist of all fully and partially paid claims submitted by the provider/supplier for the period selected for review and for the sampling units to be reviewed. For example, if the review is of Physician X for the period January 1, 2002 through March 31, 2002, and laboratory and other diagnostic tests have been selected for review, the universe would include all fully and partially paid claims for laboratory and diagnostic tests billed by that physician for the selected time period. For some reviews, the period of review may best be defined in terms of the date(s) of service because changes in coverage policy may have occurred. Sampling units with no final payment made at the time of sample selection should not be included in the sampling frame. Claims with no payment may be included in the universe from which the same frame is constructed.