What is InterQual medical necessity 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.
How do I get an InterQual criteria?
Viewing the InterQual criteria To help you understand determinations based on the InterQual clinical criteria, we give you access to a read-only version of the criteria at UHCprovider.com/policies > Clinical Guidelines > InterQual Clinical Criteria.
Does Medicare use InterQual criteria?
Does Medicare/CMS (Centers for Medicare and Medicaid Services) care about Milliman or InterQual criteria? CMS recommends admission guidelines as one of many factors to consider when making an admission decision, but it does not endorse any particular criteria or assign specific authority to them.
What is the age parameter for the appropriate application of InterQual acute adult criteria?
InterQual Acute Adult Criteria facilities for patients who are age 18 or older.
What’s InterQual?
An evidence-based clinical decision support solution for payers, providers, and government agencies who want to help ensure clinically appropriate medical utilization decisions.
How do you do InterQual?
To get started with the training you will need to visit Change Healthcare’s InterQual page, where you can find phone numbers to contact them and a form you can use to submit an application online and get in contact with them. They offer a few different ways to access their criteria.
Who owns InterQual criteria?
UnitedHealth Group
While UHC framed its decision as a response to provider requests, it coincides with the recent purchase of Change Healthcare, which maintains the InterQual Criteria, by Optum, the healthcare analytics company owned by UHC’s parent company, UnitedHealth Group.
What is the difference between Milliman and InterQual?
MCG focuses more on severity of illness and diagnosis. InterQual focuses more on intensity of service required and provides detailed day-by-day guidelines.
What is the purpose of utilization review?
Utilization review is a method used to match the patient’s clinical picture and care interventions to evidence-based criteria such as MCG care guidelines. This criteria helps to guide the utilization review nurse in determining the appropriate care setting for all levels of services across the arc of patient care.
What are utilization guidelines?
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines.
How are InterQual criteria used in skilled nursing?
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.
What happens if InterQual criteria are not met?
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.
How are InterQual criteria used in utilization review?
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.
How are InterQual Loc criteria used in medical decision making?
InterQual® LOC criteria for medical decision-making 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.