The Solventum™ Medical Necessity Dictionaries Software is an enterprise-grade solution designed to be seamlessly embedded within existing Health Information Systems (HIS) or Electronic Health Record (EHR) platforms. Its primary function is to deliver and maintain a comprehensive, up-to-date source of payer-specific medical necessity content directly into the healthcare provider's workflow. This reliable content helps hospitals and health systems achieve compliance, reduce claim denials, resolve compliance issues, and improve their overall revenue cycle.
Key Capabilities
This software provides automatic medical necessity validation at critical points in the revenue cycle, including scheduling, registration, order entry, claims processing, and billing. By integrating this intelligence at the point of service, it helps prevent errors before a claim is even submitted.
Main Features
- Payer-Specific Content: Includes National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) for Medicare Parts A and B, state Medicaid rules (e.g., Texas, Medi-Cal), and private payer policies (e.g., Aetna, Blue Cross Blue Shield affiliates).
- Automated Updates: Provides automated monthly policy updates with valid code pairs and medical necessity intelligence, eliminating the laborious task of manual data gathering and review.
- Code Validation: Supports validation for ICD-10 diagnostic codes, modifiers, and HCPCS/CPT® code pairs.
- Multi-Level Restrictions: Performs edits based on multi-level policy restrictions, including frequency, age, gender, previous diagnosis, or accompanying service.
- ABN Enablement: Facilitates the generation of Advanced Beneficiary Notices (ABNs) within the host EHR/HIS or practice management system.
- Expert Support: Clients gain access to expert support on medical necessity issues from the Solventum team of nurses, medical experts, and billing professionals.
Target Users and Use Cases
The software is primarily targeted at HIS and EHR vendors who wish to embed medical necessity functionality into their products, as well as large hospital systems and health networks that manage complex revenue cycles. The main use cases are denial prevention, proactive compliance management, and streamlining the revenue cycle to ensure accurate and timely reimbursement.
