What are Medical Necessity Policies?

Medical necessity policies define the criteria which are used to determine whether a health insurance plan will cover the cost of a specific service, procedure, or treatment. These documents play a crucial role in prior authorization processes and are a large burden for both providers and health insurance plans.

Medical policy documents are usually listed publicly by health insurance companies but are often difficult to understand. They are also frequently updated, which makes it difficult for providers to keep up with the latest requirements, and for health insurance plans to ensure that providers are following the latest guidelines.

Automating a Manual Process

Providers and their administrative staff spend a lot of time trying to understand what treatments are covered for their patients, and health plans spend a lot of time reviewing submissions by providers for adherence to their internal policies.

We've parsed thousands of medical policy documents using our AI platform to generate simple questionnaire's and rules which can be easily answered to determine eligibility. These questionnaire's can be auto-populated with answers from the patient's medical record, and can be used to generate coverage recommendations.

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