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InterQual Actionable Evidence-Based Criteria Portfolio
InterQual Level of Care Criteria help healthcare organizations assess the clinical appropriateness of patient services across the continuum of care: prospectively, concurrently or retrospectively. aligned with Medicare coverage guidelines. The criteria also include ICD-9 and HCPCS codes to facilitate the authorization process.
Medical Necessity Criteria | Beacon Health Options
* Exception: Substance Use Lab Testing Criteria is in InterQual ® Behavioral Health Criteria. If the level of care is not substance use related, Change Healthcare’s Interqual ® Behavioral Health Criteria would be appropriate. If 1-4 above are not met, Beacon’s National Medical Necessity Criteria would be appropriate.
Medical Policies and Clinical UM Guidelines - Amerigroup
Licensed Criteria InterQual. InterQual Level of Care (LOC) criteria is used by some Medicaid plans for medical necessity review for medical inpatient concurrent review, inpatient site of service appropriateness, home health and outpatient rehabilitation. The InterQual TM guidelines licensed include: LOC: Home Care; LOC: Subacute/SNF; LOC[PDF]
MagnaCare Administrative Guidelines
The goal of the program is to ensure that members receive appropriate, cost-effective care rendered by high quality providers. This goal is achieved through continual monitoring of treatment plans, provider credentials and provider performance. The program is a URAC certified utilization review program and utilizes InterQual criteria for
Manuals, Forms and Reference Tools | Buckeye Health Plan
Jan 01, 2022The request for admission or continued stay meets inpatient level of care criteria using Interqual clinical guidelines for hospital services, or: The request for admission or continued stay meets ASAM level 4.0 or 3.7 criteria. AS 4.0 Documentation Form (PDF)[PDF]
Inpatient Notification Form - Tufts Health Plan
• Persons who fail to meet other eligibility criteria • Persons who receive care that is determined not to be medically necessary authorization request form or InterQual® SmartSheets™. Note: Refer to the appropriate SNF level of care: Level 1A Level 1B Level 2 Out-of-area SNF Rehab level of care: Level 1 R1 Level 2 R2 Out-of-area[PDF]
Medical Necessity Form Rev 8 - Peoples Health
LEVEL OF CARE CHANGE, DISCHARGE ORDER, UPDATED AND PRIORITY FORMS TO . 1-866-464-5709. SERVICE REQUESTED (PLEASE NOTE, SIGNED PHYSICIAN ORDER necessity review must still meet InterQual criteria, Medicare guidelines and/or Peoples Health policy, and are subject to retrospective
Clinical Coverage Guidelines (CCGs) | Wellcare
Mar 28, 2022Out-of-State Services: WNC Out-of-State services are determined to be medically necessary, and care and services that are provided within 40 miles of the NC border in the contiguous states of Georgia, South Carolina, Tennessee, and Virginia are covered to the same extent and under the same conditions as medical care and services provided in NC, [PDF]
Surgery of the Knee - UHCprovider
criteria, refer to the InterQual o Member does not have appropriate resources to support post - operative care after an outpatient procedure; include the barriers to care as an outpati ent symptoms; (3) disability on the level of daily activities; (4) disability on a level physically more demanding than activities of daily
Prior Authorizations - Provider Preauthorization for Services | BSNENY
Urgent/emergency admissions do not require prior authorization. Once notified of admission, medical information is applied against InterQual® criteria for level of care review. Please follow these steps for Commercial and Medicare Advantage members. Important to note:

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