LIMS Medical Necessity Enforcement on Orders

Checking medical necessity at the time of order placement will allow your team to verify with a greater degree of confidence which specimens will adjudicate through insurance carrier systems and which require cash pay processing.

Two distinct medical necessity systems exist within our LIMS;

CMS LCD/NCD data sets are loaded and maintained providing a Medicare driven medical necessity check to which many insurance carriers align.

And

A manual medical necessity system exists to allow your team to create custom necessity profiles by insurance carrier and test.

Both systems will be discussed below.

CMS LCD/NCD Medical Necessity System

The CMS data set is automatically loaded into your GoRev server and maintained as new data is released. To use this medical necessity system simply click the Refresh button after you have selected tests. In the example below we have selected a Covid panel consisting of Flu A, Flu B, RSV, and SARS CoV-2. Upon clicking refresh you will see the relative 8xxxx series procedure codes and a green line for each code passing CMS medical necessity and red line for each code failing.

Note: If you do not see codes appear when you click refresh it indicates you may need to configure your test compendium with relevant billing codes as discussed here: Lab Autobill Client System Guide

On red line items you can perform two actions:

Right click on the item and you can view the CMS medical necessity article directly:

This will open your browser and present CMS' site as shown below.

Second, you can double click the red item and be presenting with a list of diagnosis codes that would satisfy medical necessity. If any of these codes are found on the order you can simply right click a code and click Add Diagnosis.

Manual Medical Necessity System by Payer

A second system exists where you can create your own diagnosis requirements by test and by payer. This is configured directly on each test in your test compendium.

Click on a test and click into the Medical Necessity tab as shown below. You can now specify diagnosis codes for All Carriers or specific carriers. The diagnosis code list is instant search and contains all ICD10 codes.

Once setup in your compendium this section of the lab order system will begin to operate. There are two modes. The GoRev team will configure this setting for you during implementation. If you need to change it simply submit a ticket.

Enforced Manual Medical Necessity = Orders will be blocked from saving until they satisfy the manual medical necessity check by adding at least one diagnosis within your configured list

Unenforced Manual Medical Necessity = Orders will be allowed to save without satisfying manual medical necessity however users will still be warned and must click to accept the warning.

Below shows the window that appears if a user attempts to complete the order without satisfying medical necessity.

The online lab portal order entry system presents medical necessity as shown below. Either system can be used at any time (in tandem).

GOREV SUPPORT TEAM

If you have any additional questions or concerns regarding this tutorial, please contact the GoRev Support Team by phone at (317) 794-3900 or by email at ask@gorev.com​

Note: Always submit an IT Support Ticket detailing the problem that you are experiencing with this portion of GoRev, if possible, as this will give GoRev Support Agents access to information that will help expedite the resolution of your issue. If you are unsure how to submit an IT Support Ticket in GoRev, please see the IT Support Ticket Creation tutorial for assistance.