Medical Necessity Review Process

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The embeddings API is currently in private beta. If. you would like access to the API, please email [email protected]

This guide outlines the steps to perform an automated Medical Necessity Review using the UMPA API to generate a decision recommendation (approve/deny/pend/escalate).

Follow these steps to submit a patient chart for adjudication against a specific medical policy.

Prerequisites

• An API key for the UMPA API
• Access to a sample patient chart in PDF format
• Knowledge of which medical necessity policy to use for adjudication

Step-by-Step Process

1. Prepare Your Patient Chart

Ensure you have a PDF file of the patient chart ready for submission. This should contain all relevant medical information for the case you want to adjudicate.

2. Select a Medical Necessity Policy

Determine which medical necessity policy you'll use for the adjudication. You'll need both the policy_id and the specific policy_title for the next step.

Important: Each policy may contain references to multiple sub-procedures. You need to select the policy_title of the specific sub-procedure that is relevant to your case.

For example, a policy for Shoulder Arthroplasty might include sub-procedures such as:

Total Shoulder Arthroplasty
Reverse Total Shoulder Arthroplasty
Hemi Arthroplasty
Revision Shoulder Arthroplasty.

In this case, you would need to select both the overall policy (Shoulder Arthroplasty) and the specific sub-procedure (e.g., Total Shoulder Arthroplasty) that applies to your patient's case.

3. Submit for Adjudication

Use the /v1/adjudicate/submit endpoint to submit the patient chart and specify the policy for adjudication.

curl --location "https://api.umpa.genhealth.ai/v1/adjudicate/submit" \
     --header 'Authorization: Bearer YOUR_API_KEY' \
     --form 'sources=@"/path/to/your/patient_chart.pdf"' \
     --form 'policy_id="POLICY_ID"' \
     --form 'policy_title="POLICY_TITLE"'

Replace YOUR_API_KEY with your actual API key, POLICY_ID with the ID of the chosen policy, POLICY_TITLE with the title of the policy, and path/to/your/patient_chart.pdf with the path to your PDF file.

4. Check Adjudication Status

After submission, you'll receive a response with a case_id. Use this to check the status of the adjudication by calling the /v1/cases endpoint.

curl -X GET "https://api.umpa.genhealth.ai/v1/cases" \
     -H "Authorization: Bearer YOUR_API_KEY" \
     -H "Content-Type: application/json"

Look for your case in the response and check its status field.

5. Wait for Completion

If the status is "in process," wait for a short period (e.g., 30 seconds) and check again. Adjudications typically take between 1-2 minutes to complete. Repeat this process until the status changes to "open."

6. View Adjudication Results

Once the status is "open," the case has been adjudicated. You can view the results in two ways:

a. Through the UMPA web interface (if available)

b. By making an API call to /v1/cases/{case_id}:

curl -X GET "https://api.umpa.genhealth.ai/v1/cases/{case_id}" \
     -H "Authorization: Bearer YOUR_API_KEY" \
     -H "Content-Type: application/json"

Replace {case_id} with the ID of your case.

Interpreting the Results

The response will include details about the adjudication, such as:

• decision_recommendation: The API's recommendation (e.g., "approve" or "deny")
• rationale: Explanation for the recommendation
• policy_matched: The policy used for adjudication
• Other relevant details about the case and adjudication process

Next Steps

After receiving the adjudication results:

1. Review the recommendation and rationale
2. Consult with medical professionals if necessary
3. Make a final decision on the medical necessity request

Important Notes

• The API's recommendation is a tool to assist in decision-making, not a replacement for professional medical judgment.
• Always review adjudication results in the context of the full patient history and current medical standards.

For any questions or issues with the Medical Necessity Review process, please contact our support team at [email protected].