Medical Guidelines Assist (MG Assist)

ZeOmega’s AI-Enabled Solution that Streamlines the Medical Necessity Review Process

Health plans and providers face growing complexity in utilization management. Reviewing large volumes of unstructured clinical documents like PDFs, scanned files, and physician notes to determine medical necessity is a time-consuming, error-prone, and inconsistent process. ZeOmega’s Medical Guidelines Assist (MG Assist) simplifies medical necessity review with AI-powered data extraction and intelligent automation. It automatically extracts and structures clinical data from unstructured documents, identifies matches and highlights key evidence, and presents insights within healthcare utilization management workflows.

Simplifying Medical Necessity Reviews

Medical Guidelines Assist combines AI-driven efficiency with essential human oversight to reduce healthcare providers’ manual workload and support faster, evidence-based care decisions. This solution supports clinicians, medical directors, providers, and office staff with:

• AI-Powered Data Extraction: Reads, extracts, and structures clinical information from EMRs, PDFs, scanned files, physician notes, and translates to clinical terminology stored in FHIR^® repositories.
• FHIR^® Compatibility: Stores clinical data in FHIR® format for seamless interoperability within modern healthcare systems
• Guidelines Hierarchy: Displays the applicable guidelines based on LOB (Line of Business), policy hierarchy that applies to the prior authorization under review. Supports health plan-specific policies, state-specific guidelines, and LCD (Local Coverage Determinations) and NCD (National Coverage Determinations).
• Auto-Populating Guideline Responses: The AI-assisted solution auto-finds and auto-populates the guideline responses based on clinical evidence from the patient’s clinical documents. The solution supports integrating with EMR systems for necessary medical records or can consume clinical documents to extract clinical evidence. Where the clinical evidence falls short, the solution can look up clinical evidence within UM platforms to avoid back and forth with providers for additional clinical documents and details, thus helping reduce turnaround times and provide timely care for the patient.
• Confidence Indicators: Indicates confidence in correlation with guidelines and evidence available. Drives Next Best Actions (NBA): Based on the clinical evidence, the solution drives the next best actions for the user to approve the prior authorization request or, in case clinical criteria are not met, suggests the NBA to Physician Review, with necessary details.
• Clinical Summary: Provides summarization of clinical documents to support medical necessity review with other third-party evidence-based guidelines like MCG or Interqual^®.
• Compliance Support: Helps organizations stay compliant with payer policies and regulatory standards, reducing audit risks. Saves the guideline responses with associated clinical evidence (from the clinical documents) for future reference and audit purposes.
• Improved Productivity: Increases efficiency and reduces turnaround time in the decision-making process.
• Reviewer Efficiency: Features like contextual data highlighting and auto-suggested responses reduce time spent searching documents
• Scalability and Lower Costs: Enables organizations to scale utilization management without proportional increases in staffing
• Consistency and Traceability: Ensures consistent, rules-driven decisions, eliminating variability from manual policy interpretation
• Strategic Value: Supports value-based care goals by enhancing care quality, audit readiness, and financial sustainability
• Integration with UM platforms: The solution leverages standards-based API that can be integrated with UM platforms for the purposes of medical necessity review.

Download the Medical Guidelines Assist product overview to explore features and use cases, or contact us to request a demo.

Additional Resources

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