Problem Statement

Referrals must be received, validated, and acted on before a specialist visit, because many payers require an authorized referral on file or the visit denies. Some services have to be checked against Medicare's Local Coverage Determination rules to confirm medical necessity before they proceed, or the claim denies as not medically necessary. Performing each LCD lookup by hand for cases in the work queues is repetitive, prescribed research that is easy to backlog.

Automation Solution

This automation performs the Local Coverage Determination (LCD) lookup for cases in the predefined work queues to confirm medical-necessity coverage.