Download Support Tool

This tool is one of the most useful and important tools in the KMC University Curriculum. Although designed for Medicare using Medicare terminology, the flowcharts apply to any type of third-party insured patient.

An important question is posed as a patient presents to the office: “Is this patient currently in an active episode of care?” If yes, the path is quite simple. If not, follow along the middle and right side of the matrix and note the additional decision-making that is necessary here.

While this tool is not meant to be absolute, it guides providers in the questions to consider when determining whether a visit will be deemed medically necessary or not. Download and review it and save it to your Medicare training materials. You may also wish to laminate a copy or place one in a sheet protector for easy reference.

The KMC University Medicare Decision Making Matrix