Fast, accurate and defensible Medicare reviews
Current Medicare review processes require navigating complex and frequently updated CMS coverage policies, often across disparate sources. This can slow decision-making, introduce variability and hinder compliance.
By converting hundreds of National and Local Coverage Determination (NCD/LCD) policies into a structured, interactive tool, Medicare Content Navigator helps payers and providers streamline the medical review process for Medicare beneficiaries while supporting adherence to the latest CMS regulations.
Key features
Integrated into your existing utilization management workflow
Medicare policies are seamlessly integrated into your existing InterQual® workflow in an actionable Q&A format. A link to the Medicare Coverage Database provides in-workflow access to all NCDs, LCDs and related policies. The review summary includes the NCD or LCD/MAC IDs.
Guide reviewers to the appropriate policy
Configurations within your workflow system direct reviewers to the appropriate NCD or LCD/MAC based on the date and location of service.
Stay current with monthly content updates and pending update flags
The criteria are updated monthly to provide your organization with the most up-to-date NCDs/LCDs. Flags are updated weekly for policies that have been revised by CMS. Access to the updated policy and revision detail are provided to ensure all reviewers are using the latest policies.
Decision Reasons and Site of Service add-ons are available
Decision Reasons is available as a content add-on to Medicare Behavioral Health, Medicare Procedures, Medicare Imaging, and Medicare Post-Acute and Durable Medical Equipment modules.
Site of Service is also available as a content add-on to the Medicare Procedures module.
Key benefits
Efficiency
Intuitive Q&A format and workflow integration eliminate the need to manually search CMS websites for policy details.
Consistency
By guiding consistent application of coverage determinations, the framework supports more standardized decisions and greater interrater reliability.
Compliance
Monthly content updates, as well as pending update notifications between releases, support compliance with rapidly changing CMS policies.
Accuracy
The solution is fully aligned with CMS policies. Steering capabilities and line-of-business criteria mapping help enhance policy interoperability.
Industry insights
On-demand webinar
Discover solutions that help you efficiently and consistently comply with CMS-4201 and CMS-0057 requirements.
On-demand webinar
Discover what to ask AI vendors and how to build a strategy that supports accelerated decision-making, reduces administrative burden and maintains clinical integrity.
Article
Learn how Decision Reasons can help enhance patient communications by providing clarity, compassion and clinical accuracy.
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