InterQual Acute Care Criteria
- Specific and objective evidence-based criteria for admission and level of care
- Directs to observation status for select conditions
- Integrates comorbidities and Social Determinants of Health (SDoH)
- Care Management Information notes for expected progress, care facilitation, and readmission considerations
- Proprietary benchmarks for Length of Stay and Percent Paid as Observation
What are the changes to the 2022 InterQual® criteria?
Beginning August 27, 2022, the Utilization Management department at Independence Blue Cross will use the 2022 InterQual ® Criteria for review of adult acute care, pediatric acute care, long-term acute care, acute rehabilitation, home care, outpatient rehabilitation, and selected inpatient procedures. View a summary of the changes online.
What is InterQual criteria for home care services?
InterQual ® LOC Home Care Services criteria The InterQual ® criteria are used by the utilization review nurses when conducting inpatient and post-acute utilization review. InterQual ® criteria are clinically based on best practice, clinical data and medical literature. The criteria are updated continually and released annually.
What is the InterQual® criteriaview feature?
If the InterQual® CriteriaView feature is available, you can track availability of recommendations as you answer questions and view additional criteria for recommendations that do not meet criteria. For additional overview information, see About CriteriaView.
What are the criteria for meeting InterQual?
Meeting Interqual usually requires two separate sets of criteria: Severity of Illness (SI): documentation of the ED diagnosis or diagnoses (not chief complaint). It is not enough to document the patient has shortness of breath; you must try to describe how sick the patient is.
What are criteria points in InterQual?
Criteria points—Refer to test results, medications, symptoms findings, or medical management. Criteria points support the reasons or indications; that is, they identify specific clinical elements that must be satisfied to justify the appropriateness of the intervention/service.
What is Milliman and InterQual criteria?
Acute inpatient hospitals use Milliman and InterQual criteria to help determine the appropriateness of care. Both sets of criteria are evidence-based screening tools used by providers and insurance companies. They do not substitute for the physician advisors' professional opinions when determining medical necessity.
What does InterQual mean?
InterQual means the McKesson Criteria for Inpatient Reviews, a comprehensive, clinically based, patient focused medical review criteria and system developed by McKesson Corporation.
What is medical necessity criteria?
Medicare defines “medically necessary” as health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
What are the 3 assessments for utilization management?
Utilization review contains three types of assessments: prospective, concurrent, and retrospective.
What is the difference between InterQual and Milliman?
InterQual's criteria are, in some respects, stricter than Milliman's, with more precise clinical benchmarks for each level of care. That could mean an uptick in denials for cases in which the patient is borderline for inpatient vs. observation or discharge vs. continued stay.
What are the three steps in medical necessity and utilization review?
Name the three steps in medical necessity and utilization review. The three steps are initial clinical review, peer clinical review, and appeals consideration.
Does Medicare use InterQual criteria?
As part of the recent Wellcare acquisition, effective August 1, 2022, all markets currently utilizing Milliman Clinical Care Guidelines (MCG) will transition to InterQual for Medicare & Medicaid Inpatient Physical Health (Inpatient Admissions, Post-acute Care, Skilled Nursing Facility, Inpatient Rehabilitation, and ...
What are utilization guidelines used for?
A set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision.
What are the four factors of medical necessity?
The determination of medical necessity is made on the basis of the individual case and takes into account: Type, frequency, extent, body site and duration of treatment with scientifically based guidelines of national medical or health care coverage organizations or governmental agencies.
What is an example of a medical necessity?
The most common example is a cosmetic procedure, such as the injection of medications, such as Botox, to decrease facial wrinkles or tummy-tuck surgery. Many health insurance companies also will not cover procedures that they determine to be experimental or not proven to work.
What is an example of medically necessary?
“Medically necessary” is a standard that Medicare uses when deciding whether to cover a health-care service or item. This applies to everything from flu shots and preventive screenings, to kidney dialysis and wheelchairs.
What are Milliman criteria?
The Milliman Care Guidelines span the continuum of patient care providing access to evidence-based knowledge and best practices relevant to patients in a broad range of care settings. This not only assists with decisions for each setting but also facilitates coordination of care and smooth patient transitions.
What are Milliman benchmarks?
Milliman Claim Variability Benchmarks™ are new industry benchmarks to help assess the quality of stochastic unpaid claim distributions used for enterprise risk management (ERM) and dynamic financial analysis (DFA), including correlations for aggregate distributions.
What is Milliman known for?
Milliman is a provider of actuarial and related products and services. Milliman serves the full spectrum of business, financial, government, union, education, and nonprofit organizations.
What does Milliman provide?
We help clients make business sense of complex technical situations, with practical intelligence that yields practical results. Milliman consultants offer specialized services in employee benefits, healthcare, investment, life insurance and financial services, and property and casualty insurance.
What is Interqual criteria?
InterQual ® criteria are a first-level screening tool to assist in determining if the proposed services are clinically indicated and provided in the appropriate level or whether further evaluation is required. The first-level screening is done by the utilization review nurse. If the criteria are met, the case is approved; if the criteria are not met, the case is referred to the Associate Vice president of Medical Affairs and/or a medical director. InterQual ® criteria cannot be used to deny a case. Only physicians can determine clinical appropriateness.
What happens if you don't meet InterQual criteria?
If the criteria are met, the case is approved; if the criteria are not met, the case is referred to the Associate Vice president of Medical Affairs and/or a medical director. InterQual ® criteria cannot be used to deny a case. Only physicians can determine clinical appropriateness. Priority Health also recognizes that the criteria can ...
What is Interqual level of care?
The InterQual ® Level of Care products cover the continuum of medical care. The richness of clinical detail allows for consideration of an individual patient's severity of illness, comorbidities, and complications in the review process in real time. InterQual ® criteria sets for acute adult, acute pediatric, inpatient rehabilitation, and subacute skilled nursing facilities contain objective endpoints for service, allowing utilization review nurses to perform reviews of admission, discharge or transfer readiness with built-in checkpoints to identify progress, plateau or achievement of goals.
Support medical necessity decisions
Assess the safest, most efficient care level by using objective, specific criteria based on severity of illness, comorbidities, complications, and the intensity of services delivered.
Promote clinical quality
Help improve patient outcomes and medical resource utilization by identifying when imaging studies, procedures, DME, MDx tests, specialty medications, and specialty referrals are appropriate.
Support behavioral health decisions
Support appropriate care by managing your delivery of mental health and substance use care, including initial and concurrent level‐of‐care decisions.
Improve review workflow and efficiency
Help improve review times and support consistency by integrating third-party content from CMS and other sources into your InterQual workflow.
Provide access to InterQual criteria
Improve usability and transparency by providing multiple InterQual access options to meet any need, from desktop to mobile to cloud.
