HMS Medical Necessity allows a hospital to validate the reasonableness and necessity of procedures being performed based on both national coverage determination (NCD) and local coverage determination (LCD) policies.

Features & Benefits
The HMS Medical Necessity Solution notifies clinicians and hospital staff of requested procedures that do not meet LMRP criteria and automatically prints the Advance Beneficiary Notice as well as a Physician Notice. If used in HMS Order Communications or Patient Scheduling, the patient may decide whether to decline the charge, accept the charge or file a claim if it is believed that the incurred charge will be covered by the insurance plan.

Key features

• Automatic notification: The solution automatically notifies the hospital department of procedures being requested that do not meet LMRP.
• Cost safeguards: A user-defined Advance Beneficiary Notice (ABN) and a Physician Notice are generated based upon the patient's decision to accept or decline financial responsibility for tests that are not deemed necessary by the hospital.
• Timely compliance: To ensure compliance, HMS can input the constantly updated LMRPs on a facility's system on a monthly or quarterly basis. Plus, the solution ensures billing compliance on the UB92 form by placing charges in covered/non-covered columns with appropriate modifiers and condition codes.