Consumer-level patient education and decision reason text
Efficiently and consistently communicating the reason for determination to members and patients can be challenging. The process of creating and maintaining a library of content can be time-consuming and poses the risk of inconsistent communication. The content may also lack the required components to meet regulatory and accreditation standards.
To address these challenges, Decision Reasons provides organizations with a library of consumer-level content aligned with InterQual® and industry criteria. It’s used to communicate why a service may not be clinically appropriate for a member or patient.
Key features
Clear, empathetic content that explains clinical decisions
Content is written at the 5th- to 7th-grade reading level and personalized to the member or patient. Where applicable, clinical reasons content prompts users to fill in blanks with patient-specific clinical information.
Robust, evidence-based library of content
Access a library organized by InterQual criteria and industry content subsets, offering the latest evidence to support consistent decision-making. Content includes a clear reason for the determination and a list of specific clinical reasons based on the member's scenario.
Integrated into existing utilization management workflows
Staff can select relevant Decision Reasons content as a final step in completing the InterQual medical necessity review. Selected content is included in the review summary and is ready to be incorporated into communications.
Provider-facing content to support transparency
Organizations can opt to include a provider-facing summary that identifies the specific components of criteria that were not supported by clinical documentation. This helps improve transparency and collaboration between payers and providers.
Support for accreditation and regulatory compliance
Content structure, readability and personalization support required components of determination letters aligned with NCQA and URAC standards. It also supports payer compliance with the CMS Interoperability and Prior Authorization Final Rule (CMS-0057).
Available modules
Decision Reasons is available as an add-on to the following InterQual® Criteria and industry content modules:
- InterQual® Acute Adult Criteria
- InterQual® Acute Pediatric Criteria
- InterQual® Inpatient Rehabilitation Criteria
- InterQual® Subacute and Skilled Nursing Criteria
- InterQual® Long-Term Acute Care Criteria
- InterQual® Adult and Geriatric Psychiatry
- InterQual® Child and Adolescent Psychiatry
- InterQual® Substance Use Disorders
- InterQual® Behavioral Health Services
- InterQual® Durable Medical Equipment Criteria
- InterQual® Imaging Criteria
- InterQual® Procedures Criteria*
- Medicare Behavioral Health Navigator
- Medicare Imaging Navigator
- Medicare Procedures Navigator*
- Medicare Post-Acute and Durable Medical Equipment Navigator
*Available for the highest utilized subsets capturing 95% of usage based on review data.
Key benefits
Efficiency and consistency
Reduce manual effort with ready-to-use content aligned to InterQual criteria and industry content, helping streamline workflows and maintain consistency across teams.
Member satisfaction
Content is aligned with consumer preferences for detailed, empathetic and personalized communication.
Accreditation and regulatory support
Decision Reasons supports payers in meeting regulatory and accreditation standards such as CMS-0057, NCQA and URAC.
Enhanced engagement and transparency
Strengthen engagement and transparency across payers, providers and members through clear, detailed communication that builds trust.
Industry insights
Article
Learn how Decision Reasons can help enhance patient communications by providing clarity, compassion and clinical accuracy.
On-demand webinar
Explore market conditions driving the outpatient shift, considerations for patient selection and current opportunities in the ambulatory space.
Article
Evidence-based medicine improves quality of care while reducing the cost of care.
Product information and resources
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Download case study
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Case study
Decision Reasons case study
Learn how a health plan with over 2 million covered lives in the Midwest increased efficiency and consistency of authoring member communications with Decision Reasons content.
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Download case study
PDF
Case study
Decision Reasons case study
Discover how one mid-to-large sized health plan in the Midwest utilized Decision Reasons content to increase efficiency and consistency of authoring member adverse determination letters.
Complementary solutions
Solution suite
InterQual
Discover our evidence-based clinical decision support solution for payers, providers and government agencies.
Software
InterQual Criteria
Our comprehensive solution offers clinical decision support designed to strengthen patient outcomes and reinforce appropriate utilization.
Software
Industry Content Navigator
Get structured industry content to support consistent application of third-party content and policies and improve review workflow.