National Coverage Database and Prior Auth Rules made Accessible via Generative AI

Ethan Siegel
by Ethan Siegel


The Prior Auth Form Database

GenHealth’s Prior Auth Compliance Product

Background of prior authorization

In today's world of healthcare, coverage and prior authorization requirements prove to be a necessary but significant challenge for health plans, providers, and patients. The requirements are esoteric and disjointed and create considerable administrative burdens which lead to denials or delays in care.

Health plans require prior authorization and utilization management guidelines to limit unnecessary intervention which may lead to increase healthcare costs. However, the administration of these rules incur high personnel and technical costs, especially when required to maintain the latest evidence based guidelines. Providers must navigating intricate rules, with nuances between different plans, taking time away from patient care. For individuals, the result may be unexpected costs, delays in treatments, and denials of life saving interventions.

Recognizing these challenges, the government has proposed regulations to streamline the process. The rules are a great start but remain years out and still leave room for improvement. That’s why at we have built the world's first prior auth and medical policy database that allows anyone to better understand the requirements and compare rules across plans. By the way, we did this all using our generative AI model for healthcare.

Coverage Policies and Prior Authorization Forms

The majority of prior authorizations naturally occur in the elderly population of patients in Medicare and Medicare Advantage plans. Policies describing coverage are produced by CMS and the Medicare Advantage plans.

CMS: National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)

CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) are documents issued by the Centers for Medicare and Medicaid Services (CMS). NCDs are used to set national policy for Medicare coverage for specific medical procedures, devices, or services, and apply to all states. On the other hand, LCDs are issued by Medicare Administrative Contractors and provide coverage guidelines for specific items or services within a specific region. Both NCDs and LCDs are vital in the healthcare industry as they guide coverage decisions across different healthcare services and procedures for patients with Medicare.

CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) are crucial to prior authorization as they provide guidelines for coverage of specific medical procedures, devices, or services. Prior authorization is a process where a healthcare provider must obtain approval from a health insurance company before providing a medical service to a patient to ensure the service is covered under the patient's health plan. NCDs and LCDs guide this process by outlining which services are medically necessary and covered nationally or regionally. Therefore, they are key reference documents when creating commercial medical necessity policies. Understanding and effectively parsing these documents is critical to ensure correct application of coverage rules and to avoid unnecessary costs or denials of service.

Medical Necessity Policy

Commercial health insurance plans also have their own analog to NCDs and LCDs, sometimes called "medical necessity policies" or “medical necessity guidelines.” These policies outline the criteria that must be met for a procedure, service, or device to be considered medically necessary and therefore, covered under the plan. The creation and management of these policies is a complex task, requiring deep knowledge of medical standards and regulatory guidelines, as well as CMS’s NCD’s and LCD’s. As a result, some insurance plans may outsource the development and maintenance of these policies to specialized firms like Interqual and MCG Health. These companies have expertise in synthesizing medical evidence and regulatory guidelines into comprehensive and usable policies, bringing efficiency and consistency to the process.

Claims Adjudication and Prior Authorization

Claims adjudication, the process of determining the insurer's payment or financial responsibility after the member's insurance benefits are applied, heavily relies on these NCD, LCD, and commercial medical necessity policies. In many ways, the process is very similar to prior authorization. In both cases, medical policy need to be transformed into automated "rules" that can guide the decision-making process. This is a challenging task due to the frequent changes and updates in these policies. It requires constant monitoring and updating of the rules to ensure they align with the most recent guidelines.

This task is further complicated for physicians, who have to deal with different medical necessity policies for different payers. Each payer may have unique coverage guidelines, and the physician must be aware of these differences to ensure services provided are covered. This can become an administrative burden, taking time away from patient care. Hence, effective parsing and understanding of these documents and guidelines are crucial to streamline the process and ensure accurate and efficient claims adjudication and service delivery.

Utilization Management at a Health Plan

Payers have dedicated Utilization Management teams who are tasked with the crucial job of reviewing prior authorization requests and complex claims submissions from healthcare providers. This job is not only time-consuming but also requires in-depth knowledge and understanding of the various medical necessity policies. These teams need to ensure that the requested medical procedures, devices, or services meet the necessary criteria for coverage as outlined in the CMS NCDs, LCDs, and commercial medical necessity policies. With each payer having unique coverage guidelines, these teams must be well-versed with the policy differences to accurately determine if the requested services are covered under the patient's health plan. Therefore, effective parsing and understanding of these documents are vital to facilitate their work, reduce administrative burden and ensure accurate and timely decision-making in the prior authorization and claims adjudication processes.

GenHealth’s Approach

Many health insurance plans publicly list their medical necessity policies, though these documents are typically in PDF format. This format presents a challenge for both providers and payer utilization management teams, as it's difficult to parse and use effectively due to lack of structure. Despite these challenges, we've managed to download thousands of these documents and have used our AI systems and ETL processes to automatically extract structured information, significantly enhancing the usability and accessibility of the information contained within.

Our advanced AI systems and ETL processes are designed to automatically extract crucial information such as effective dates, last review dates, and policy numbers from the CMS NCDs and LCDs, which are typically in PDF format. Most importantly, our systems can identify and structure questions and rules embedded within these documents. These structured questions and rules can then be used to facilitate decision-making processes, enabling quick and accurate determination of whether a patient's procedure should be covered under their health plan. This automation significantly enhances the usability and accessibility of the information contained within these documents, thereby streamlining the claims adjudication and prior authorization processes.

Extraction “Citations”

In addition to structuring questions and rules from the CMS NCDs, LCDs, and commercial medical necessity policies, our sophisticated AI system can also tie these structured elements back to the exact sentences in the original documents. We refer to these links as "citations." This feature enhances the transparency of our system, providing clear traceability and references for each question and rule, which can be crucial during audits or reviews. Moreover, our system is capable of automatically extracting relevant data from patient records to auto-fill these questionnaires, further streamlining the prior authorization and claims adjudication processes. This automation not only reduces manual work and potential errors but also ensures a more accurate and efficient application of coverage rules.

Our AI system and ETL processes not only streamline the handling of medical necessity policies but also have the potential to dramatically reduce the time spent by Utilization Management teams and physician administrators. For Utilization Management teams, the automatic extraction and structuring of rules from CMS NCDs, LCDs, and commercial medical necessity policies significantly speed up the review of prior authorization requests and complex claims. This allows for faster, more accurate decisions, reducing the administrative burden on these teams and enabling them to focus on more critical tasks.

For physician administrators, our system's ability to tie structured elements back to the original documents and auto-fill questionnaires can cut down on the time spent filling out different forms for different payers. This reduces the administrative load, allowing physicians to reclaim valuable time to focus on patient care.

The adoption of this system in utilization management at payer organizations represents a significant stride in operational efficiency. By automating the integration of structured elements with original documents and streamlining the form-filling process, it alleviates the administrative burden. This advancement allows payers to focus more on the critical aspects of utilization management, such as policy adherence and cost control, while maintaining high standards in patient care. Ultimately, this technology fosters a more efficient healthcare system, where the focus is on enhancing care quality and decision-making, rather than being mired in paperwork.

Meet the regs and go beyond

Furthering our journey into healthcare efficiency, we are also preparing for the upcoming regulatory changes. The Centers for Medicare and Medicaid Services (CMS) have recently proposed new regulations to automate the prior authorization process by the end of 2025. At GenHealth, we are already ahead of the curve.

Building upon these policies and rules that we codified, we have developed a solution that not only meets these new regulations, but goes beyond. We are working closely with health plans to automate and streamline the prior authorization process, ensuring compliance with these pending CMS regulations. The secret behind our efficiency is our own generative AI model trained on medical event records. Combined with traditional LLMs, it automates the extraction of rules from medical policies, leading to a deeper understanding of utilization management.

Our solution is multi-faceted. The Prior Authorization Automation & Compliance feature employs a data crawler to scan through your PDFs, web pages, FHIR, CDA, docs, and more. Updated daily or when changes occur, it's backed by the expertise that has already brought compliance to over 50 plans. Our AI Rules Processing uses our generative AI model to extract rules, automatically build forms, and process prior authorizations with no need for manual logic. Our AI does the work.

We also provide UM Admin Apps that allow you to validate rules, create PA reports, manually intervene when necessary, and modify logic. You can interact with reports using chat and text, streamlining communication. Our Prior Auth API connects to FHIR to execute PA coverage requests and provide logs and reports with human-readable PA logic explanations. And of course, the plan's FHIR Server is DaVinci Compliant and supports CRD & DTR.

But we don’t stop at meeting regulations. Our solution offers automatic rule extraction through AI, industry intelligence for PA forms, utilization insights from medical models, and personalized prior authorization cost and outcome predictions.

Our goal is to revolutionize the way healthcare providers and organizations navigate the complex landscape of prior authorization, enhancing efficiency and reducing administrative burdens, all while ensuring compliance with the upcoming regulations. With GenHealth, you can be assured of being on the forefront of healthcare efficiency and patient care.