By using the medical necessity review, you can determine if the services that are being covered or provided are determined to be medically necessary and should continue to be covered. Industry guidelines such as Change Health's InterQual or MCG’s CareWebQi are used to create consistent, evidence-based decisioning.

The medical necessity review case is a child case of the admission case. This case is automatically added as a child case of the admission case for certain diagnosis and procedure codes and also is based on the length of stay. The implementation layer can configure these values.

If the admission case requires a medical necessity review (initial or concurrent), the discharge worksheet is not initially added under the discharge plan in the admission case tree. The system adds the discharge worksheet at the time of completion of the medical necessity reviews. Otherwise, if the admission case does not require an initial or concurrent review at this point, the discharge worksheet is directly added to the discharge plan in the admission case tree and provides you with the option to add a medical necessity review on an ad-hoc basis.

If nurses determine that the progression criteria, used to determine if additional coverage should be provided, is not met, then you need to complete these fields:

• Authorized from date
• Authorized To Date
• Days denied
• Denial reason

For more information about medical necessity reviews, see the Pega Care Management Business Use Case Guide.

The following list describes items that are related to the Medical necessity review Microjourney:

• Data Model for medical necessity (initial or concurrent)
• Key rules