CMS Pub. 100-08, ch. 8, § 8.4.3.2.1

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.