Know what the payer needs before you submit.
Clinicians own the medical-necessity call. The system catches what's missing before submission and learns from every denial.
An order enters the queue.
Pulled from the EHR the moment the order is signed. The system grabs the order plus the relevant clinical documentation, problem list, imaging, and prior conservative care notes.
- 22 min ago Order #PA-4817 MRI lumbar spine w/o contrast Assembled
- 11 min ago Order #PA-4819 CT abdomen + pelvis w/ contrast Assembled
- just now Order #PA-4821 MRI lumbar spine w/o contrast New
Order routed to the exact governing policy.
Code, payer, and plan resolve to the specific medical-necessity policy section. Your payer-policy library is captured and maintained at kickoff, then kept current as plans update.
Order #PA-4821
Service requested
CPT 72148 · MRI lumbar spine without contrast
Indication
Chronic low back pain with radiculopathy
ICD-10 M54.16, M54.5
Coverage
[Payer] · commercial PPO
Plan tier: standard
- Documented symptoms 6+ weeks
- Failed conservative care: PT or NSAIDs
- Neurologic deficit or red-flag symptom on exam
- Imaging will change management
Documentation checked against criteria. Gaps surfaced.
Every criterion is compared against the chart. What's satisfied gets cited. What's missing gets listed by name, before anything is submitted. A clinician owns the necessity attestation; the system never auto-clears it.
Order #PA-4821
MRI lumbar · [Payer] MN-RAD-014
The auth packet writes itself.
Criteria-satisfying evidence pulled, cited inline, and highlighted for the reviewer. Submitted via payer portal or clearinghouse. Full audit trail attached.
Clinical notes attached
3 visit notes, problem list, medication list. Symptom-duration line highlighted.
Conservative care evidence
NSAID trial dates, PT documentation added by [Provider] post-assessment. Both highlighted for reviewer.
Necessity attestation
Signed by [Provider]. Clinician affirms criteria met. System logs attestation source and time.
Submitted to [Payer]
Sent via payer portal. Confirmation #AUT-882-4821 returned at 10:42 AM.
Tracked to determination, appeal basis ready.
Status polls the payer until a determination posts. On denial, the system surfaces the exact appeal basis based on the policy section and the documentation already on file.
Order #PA-4819 · CT abdomen + pelvis
[Payer] MN-RAD-022 · submitted 2 days ago
Denial reason from [Payer]
- Conservative care duration not clearly documented for the 6-week threshold required by MN-RAD-022 section 4.1.
Appeal basis surfaced
PT records dated 02/18 through 04/01 already exist in the chart and were not in the original packet. Eight weeks of documented conservative care satisfies section 4.1. Re-submission packet assembled with PT records cited inline. [Provider] reviews and signs.
Every denial sharpens the next assessment.
A denial isn't a dead end. The reason gets tagged, mapped to the policy section, and fed back into the necessity assessment. The next order that touches the same code, payer, and plan gets the harder check up front.
Denial received
Reason: insufficient documentation of conservative care duration.
Mapped to policy
Linked to [Payer] MN-RAD-022 section 4.1. Library entry updated with denial pattern.
Next assessment
Future orders flagged sooner. Stricter check on PT documentation before submission.
Denial reason feeds back into Stage 03. The library and the necessity assessment both update. Every denial sharpens the library and the next assessment. Compounding over time.
Same clinicians. The back-and-forth disappears.
Your clinicians still own every necessity call. They just stop chasing missing documentation and stop sitting on hold.
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