Medical Necessity Checking (MNC) occurs within CPOE using a 3rd party database provided by 3M. The use of this 3rd party database requires licensing, subscription, and setup by your Account Manager. Please contact your Account Manager for details.
When activated, your facility can determine if medical necessity checking is Off, Automatic, or Manual. To make this setting, go to Maintenance > General > Medical Necessity and select one of the following in the Medical Necessity Configuration Settings section:
Off: No medical necessity checking will be accessible during CPOE.
Automatic: Medical Necessity Checking is automatically done for all patients/orders meeting the patient class and financial class criteria (outpatient and Medicare).
Manual: Medical Necessity Checking only occurs when the Save and Check Necessity button is clicked from the Order Details fly over (single order at a time).
During CPOE, you have several options for checking medical necessity:
From the Order Details window, click the Diagnosis button to select the appropriate diagnosis for the order. (Note: Diagnoses can be added in this window by clicking the "plus" button.) Then, click Save and Check Necessity. This option allows you to save the order to the Order Creation page and initiate the call to 3M to check for necessity prior to submitting the order. The order then appears in the list for submission and the MNC column displays the result from the check.
If the MNC column says PASS, then the order is collapsed and the order is ready for submitting from the Order Creation page.
If the MNC column says FAIL, then the order is expanded with the Medical Necessity fields displayed. You have 3 options:
You can change the order and/or the diagnosis using the Edit Order button. Then repeat the process by clicking the Save and Check Necessity button in the fly over.
If you do nothing and Submit the order, the order is placed on HOLD (shaded in yellow) and the Patient Agrees to Pay? and ABN Signed? fields need to be addressed prior to the order being processed/completed.
Or, complete the fields at this time:
Patient Agrees to Pay? In the Patient Agrees to Pay field, select Yes. Then, click Print ABN. Have the patient complete and sign the form, then send it to Medical Records Dept. for scanning into the record (or an alternate facility policy). Or, if you select No, the order is submitted and is displayed on the Orders Tracking page as a cancelled order. If you select Hold, the order goes to a Hold status and appears on the Orders Tracking page.
ABN Signed? In the ABN signed field, check Yes or No.
In some cases, you may receive a message from 3M indicating it cannot make a decision for the checking and will ask the user to select Pass or Fail based on information in the message, i.e., This procedure is only covered every 30 days. Has the patient had this procedure completed at any facility in the past 30 days?
Go to Reports > General Reports > ABN Report.
Select From Date and To Date to indicate the range for the report. Note: The date is the Start Date of the order that was placed or attempted to be placed.
In the Status field, select the status you would like to display in the report: Pass, Fail, or All.
Click Generate Report. The report is displayed in the browser window including the status of the check, and the details/answers to the questions "ABN Signed?" and "Agreed to pay?" for each line item.
This checking typically occurs for Outpatient type patients with Medicare as a payor. Setup is required in several areas to ensure that the checking is working properly:
Licensing: An annual subscription is required. Contact your Account Manager for details.
Patient Class setup in Patient Registration: The Patient Class has to have the Patient Class Type of outpatient, ED, recurring, clinic, or home health (2,3,4,5, 8 and 10) to be included.
Insurance Company setup in Patient Registration: In PR, the Insurance company must be set to a financial class that is associated with Financial Class Type: Medicare or Medicare Part B.
Order items setup in Clinical Documentation: In CD, ensure that order items are attached to charge codes that have an associated Procedure code. (Procedure codes are added in the Billing module.)