Medical Necessity Inclusion Maintenance

You can build your own professional and institutional medical necessity edits via the Medical Necessity Inclusion pages. Medical necessity exclusions can be created to apply to all claim types or for any single payer on your working payer list. CPT, modifier, and ICD or revenue diagnosis code combinations entered on these pages will appear on future Claims in Error reports along with the messages you specify.

We recommend you do not populate the user inclusion tables until after you have been scrubbing submission files for some time and are familiar with the process. You may find there are existing medical necessity edits appearing on the Claims in Error report that already meet your needs.

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