Universal Clinical Coverage
Introducing Universal Clinical Coverage
Providers spend approximately $10 billion on obtaining prior authorizations and $19.7 billion on denial reviews annually. Today, verifying insurance coverage for medical care involves multiple steps and fragmented sources of truth. For patients, coverage verification further complicates the healthcare transaction and can delay care. For providers and payers, it creates considerable administrative overhead and financial waste.
To eliminate the administrative burden and confusion providers and patients face in navigating bespoke clinical requirements of every health plan, we propose a standard chassis for rules-based clinical coverage modeled off of Medicare National and Local Coverage Determinations. With government support, there may be a core set of coverage determinations required by all group purchasers in the United States. From there, group purchasers may compete in an open market of transparent coverage decisions for new and emerging therapies, wellness benefits and more.
by streamlining prior authorizations and reducing claim denials through open-license, rules-based, real-time coverage determinations for Standard Service Packages (SSPs).
The library
For each Standard Service Package (SSP), there is a corresponding Universal Clinical Coverage rule set. Each rule set includes one or more coverage scenarios that reflect the most common coverage criteria for that service. This library is updated on an annual basis to reflect the latest clinical guidelines.
SSP Code | Category | Type | Status |
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