Solventum™ Medical Necessity Dictionaries Software

Keeping healthcare information systems up-to-date with Medicare regulations, Medicaid rules and private payer requirements— especially with ICD-10-based rules—is no small feat today, and few areas are as volatile and compliance-sensitive as medical necessity.

The Solventum Medical Necessity Dictionaries Software deliver timely, updated medical necessity content for use throughout the revenue cycle, including:

• NCDs and LCDs
• ICD-10 diagnostic codes and modifiers
• Other state Medicaid and payer-specific data
• Multi-level policy restrictions, including frequency, age, gender, previous diagnosis or accompanying service

Solventum knows that healthcare software and electronic health record (EHR) vendors like you need and want to deliver medical necessity functionality to your clients. Healthcare organizations must comply with medical necessity, but as a vendor do you have the in-house ability and expertise to deliver?

Consider what medical necessity means today:

• The Centers for Medicare & Medicaid Services (CMS) requires hospitals to check 100 percent of Medicare outpatient services
• Hospitals must check prior to rendering services
• An Advanced Beneficiary Notice (ABN) must be generated and signed for services that carriers and Medicare Administrative Contractors (MACs) may not reimburse

And how complex is Medicare medical necessity? CMS creates National Coverage Determinations (NCDs) that apply to the entire country. Contracted fiscal intermediaries (FIs), carriers and MACs create medical necessity policies known as Local Coverage Determinations (LCDs) that apply to local service areas.

All healthcare providers must check all pertinent policy regulations to determine medical necessity, which means they face between 150,000 and 500,000 unique ICD and HCPCS/CPT® code pairs in the Medicare policies, depending on their state. In addition, these codes can change on both a monthly and ad hoc basis.

The Solventum Medical Necessity Dictionaries Software can be embedded within an existing HIS or EHR to provide automatic medical necessity validation—consistently and reliably—during scheduling, registration, claims processing or wherever else in the revenue cycle your customers require.

As a software vendor, you and your customers can benefit from these features:

• Eliminate the laborious tasks of gathering medical necessity data and performing monthly manual reviews
• Receive automated monthly policy updates with valid code pairs and medical necessity intelligence
• Gain access to expert support on medical necessity issues from the Solventum team of nurses, medical experts, and billing professionals
• Protect against potential allegations of fraud and abuse through accurate and frequent updates and current content
• Facilitate accurate and timely Medicare reimbursement, proactively manage A/R days, and help reduce denials, write-offs, and the cost of correcting rejected claims
• Perform edits for medical necessity, frequency, and others
• Enable ABNs within an EHR, HIS or practice management system

Solventum Medical Necessity Dictionaries Software is available as a standalone solution or bundled with other coding compliance edits, grouping software and reimbursement calculation software through these other Solventum products and platforms:

• Solventum™ Grouper Plus Content Services (GPCS), a Solventum-hosted, cloud-based method of content distribution into another system’s workflow
• Solventum™ Core Grouping Software (CGS), a Microsoft® Windows®-based application that can be used for batch or interactive processing