Analytics - Medical Necessity Validation


Prevalent provides a validation tool for both Medicare and commercial payers that determines if the procedure meets the medical necessity requirements for a claim to be paid.  


A partial list of our validations is in the checklist below:

Medical Necessity Validation

Valid medical necessity
Procedure not covered for diagnoses according to coverage decision
Never covered procedure according to coverage decision
Diagnosis never covered
Procedure has warning in coverage decision
Procedure identified as permissive in coverage decision
Procedure has frequency restrictions in coverage decision
Missing primary diagnosis for medical necessity – DEPRECATED
Required secondary diagnosis missing according to coverage decision
Override medical necessity, ABN on file (-GA)
Override medical necessity, ABN not on file expect denial (-GZ)
Override medical necessity, statutory exclusion (-GX, -GY)
Service requires at least one associated diagnosis code

Diagnosis Validation

Valid diagnosis
Invalid diagnosis code (never valid)
Truncated diagnosis code
Invalid diagnosis code for date of service
Diagnosis requires POA indicator

Medicare Fee Calculation and Adjustment

Medicare fee paid
Billed charge paid
Medicare does not price this procedure
Fee adjustment failed

Patient History Validation

Procedure is in global period of previous procedure
New patient code may be inappropriate, as patient has been seen within three years of service date
Established patient code may be inappropriate, as patient has not been seen within three years of service date
Procedure violates frequency restrictions in coverage decision
Procedure must be in global period of previous procedure, no global period found

Medically Unlikely Edit Testing

Acceptable number of service units for procedure
Units greater than MUE maximum for procedure

Custom Tests – (Return Fields Vary)

Data missing, could not perform custom test
Flagged for review based on custom requirements
Custom sex requirement not met
Custom procedure requirement not met
Custom place of service requirement not met
Custom modifier requirement not met
Custom age requirement not met
Custom medical necessity edit triggered
Custom supervising provider requirement not met
Procedure is always bundled, and will not be separately reimbursed
Insured ID does not match format specifications
Insured Group or Policy Number does not match format specifications
Custom charges requirement not met
Physician not listed on schedule
Custom units requirement not met
Referring ID does not match format specifications
Custom frequency requirement not met
PQRI denominator criteria met
Custom occurrence span requirement not met
Custom taxonomy code requirement not met

Outpatient Prospective Payment System Edits

Invalid diagnosis code
Diagnosis and age conflict
Diagnosis and sex conflict
E-diagnosis code can not be used as principal diagnosis
Invalid procedure code
Procedure and sex conflict
Non-covered for reasons other than statute
Service submitted for denial
Service submitted for FI/MAC review
Questionable covered service
Inappropriate specification of bilateral procedure
Inpatient procedure
Mutually exclusive procedure that is not allowed by NCCI even if appropriate modifier is present
Code2 of a code pair that is not allowed by NCCI even if appropriate modifier is present
Medical visit on the same day as a type T or S procedure without modifier 25
Invalid Modifier
Invalid date
Invalid age
Invalid sex
Only incidental services reported
Code not recognized by Medicare; alternate code for same service may be available
Partial hospitalization service for non-mental health diagnosis
Insufficient services on day of partial hospitalization
Only Mental Health education and training services provided
Terminated bilateral procedure or terminated procedure with units greater than one
Inconsistency between implanted device or administered substance and implantation or associated procedure
Mutually exclusive procedure that would be allowed by NCCI if appropriate modifier were present
Code2 of a code pair that would be allowed by NCCI if appropriate modifier were present
Invalid revenue code
Multiple medical visits on same day with same revenue code without condition code G0
Transfusion or blood product exchange without specification of blood product
Observation revenue code on line item with non-observation HCPCS code
Inpatient separate procedures not paid
Partial hospitalization condition code 41 not approved for type of bill
Revenue center requires HCPCS
Service on same day as inpatient procedure

Medicare Code Editor Edits

Invalid diagnosis or procedure code
E code as principal diagnosis
Duplicate of PDX
Age conflict
Sex conflict
Manifestation code as principal diagnosis
Questionable admission
Unacceptable principal diagnosis
Non-covered procedure
Bilateral procedure
Invalid age
Invalid sex
Invalid discharge status
Limited coverage – procedure type
Wrong procedure performed
Procedure inconsistent with length of stay




Prevalent, Inc. a subsidiary of Axcension, Inc.

For more information or to see a demo of our product please contact us today.

23537 Kingsland Blvd Suite 124, Katy, TX 77494    l    (832) 413-5990  contactus (@)




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