Medical Necessity Determination Workflow
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Quick Answer
The Medical Necessity Determination Workflow uses AI to evaluate whether requested services meet clinical appropriateness standards and payer coverage criteria. AI matches patient-specific clinical indicators to evidence-based guidelines and payer policies to determine medical necessity.
Definition
Key Points
- Extracts clinical indicators from patient documentation
- Maps indicators to payer medical policy requirements
- Evaluates patient-specific contraindications and risk factors
- Compares against evidence-based clinical guidelines
- Generates medical necessity rationale with citations
- Identifies supporting and contradictory evidence
- Provides confidence score on determination
- Recommends additional evidence to strengthen case
How It Works
Clinical Data Extraction
Extract relevant clinical data: diagnoses, symptoms, test results, prior treatments, comorbidities, contraindications.
Payer Criteria Retrieval
Retrieve payer-specific medical necessity criteria for requested service: eligibility requirements, clinical indicators, exclusions.
Indicator Matching
Match patient's clinical indicators to payer criteria requirements. Identify which criteria are met, partially met, or not met.
Evidence-Based Guidelines
Compare against clinical practice guidelines (ACR, AHA, NCCN). Verify requested service aligns with standard of care.
Contraindication Check
Evaluate patient-specific contraindications, allergies, drug interactions, comorbidities that might affect appropriateness.
Medical Necessity Rationale
Generate rationale explaining why service is medically necessary. Cite clinical evidence, guidelines, and payer criteria.
Confidence Scoring
Provide confidence score (0-100) on determination. Lower scores indicate need for additional documentation or clinical review.
Evidence Recommendations
If confidence low, recommend specific additional evidence: lab results, specialist consultations, imaging studies.