A medical necessity check is performed when an order is submitted and all of the following conditions are met:
- The order is a lab order
- The Medical Necessity Required option is configured for the lab order in the form's Order Form Settings
- The selected patient's insurance is Medicare
Medical Necessity Check Results
When a Medical Necessity Check is completed, a Medical Necessity Check Results panel is displayed. A reason is displayed next to each orderable code in the panel. The following statuses are available:
| Status |
Description |
Advance Beneficiary Notice |
| Pass |
The lab code/ICD combination is allowed. |
N |
| Fail |
The lab code/ICD combination is not allowed. If the patient wants to proceed with the lab test, the must pay its cost. |
Y |
| Unverified |
No CPT code is configured for the lab test. The system cannot verify the lab code/ICD combination. |
N |
| Restricted |
The test or procedure is restricted. Restrictions may include restrictions on the frequency/timing or on who can perform the procedure. The health care provider must review and understand the Centers for Medicare & Medicaid Services (CMS) guidelines in the CMS Medicare Coverage Database. |
Y |
| Error |
No ICD code was included when the order was submitted. |
N |
Advance Beneficiary Notice
An Advance Beneficiary Notice (ABN), also called a waiver of liability, is a notice that a provider can print and give to a patient when the Medical Necessity Check receives a Fail or Restricted status for one or more lab codes on the order.
Complete the following steps to print an Advance Beneficiary Notice:
- In the Medical Necessity Check Results panel's heading, select Display ABN.
- In the Document Viewer, select Print or Download.