Medical Necessity Checking

The Medical Necessity Failed window displays if an item ordered through Scheduling has associated procedures that conflict with the visit’s diagnoses, deeming them medically unnecessary for the diagnoses. Ancillary procedures (CPT codes) are associated with an item in Item Maintenance and mapped to specific diagnoses.

RCM Cloud^® checks the item’s ancillary procedures and determines whether they are mapped to a diagnosis in the Medical Necessity Mapping table. If they are mapped to each other, the item passes the medical necessity check. If they are not, the item fails the check and the Medical Necessity Failed window displays and allows the user to continue or cancel the order.

When the check fails, the user is given the option of printing an advanced beneficiary notice (ABN), which includes information about the item/service that is not covered.

Note: The visit’s patient type and payer must be configured for medical necessity checking.

Medical Necessity Check in Scheduling

The Medical Necessity Check in Scheduling happens when the appointment is created on the Appointment Scheduler. If it fails, the Medical Necessity Failed window displays, listing the item, diagnosis, and procedure.

To proceed, select one of the following, then click Save:

• Yes – Continues scheduling the appointment.
• No – Does not schedule the appointment but saves medical necessity checking information and keeps the reservation in the Appointment Scheduler (if scheduling by drag and drop).
• Reason – If No is selected, enter the required explanation in the text field.
• Cancel – Cancels the appointment, returns the user to the Scheduling wizard, and keeps the reservation in the Appointment Scheduler (if scheduling by drag and drop).

After making a selection, a the ABN window displays and gives the option of printing the ABN.

If the user clicks Yes, the ABN opens in a Reporting Services report and can be printed, and a PDF version is attached to the visit.