When we receive a request for authorization or prior approval, our utilization review nurses use Change Healthcare’s InterQual® criteria to determine if the services and level of care are clinically indicated. If the criteria are met, the case is approved; if the criteria are not met, the case is reviewed by a physician.
InterQual criteria are clinically based on best practice, clinical data and medical literature. They are updated continually and released annually.
Blue Cross Blue Shield of Massachusetts makes the criteria available to you through the Transparency Tool. Referring to the criteria in the tool may help you:
|Before a service is rendered:||Determine if it will meet InterQual® criteria.|
|After a service is rendered:||Understand how we made a medical necessity determination for a service that has been rendered.|
To access the InterQual application on our website, log in and go to Clinical Resources>Coverage Criteria & Guidelines>
InterQual Criteria and SmartSheets. Then click Go Now.
Through our Authorization Manager eTool, Blue Cross Blue Shield of Massachusetts-participating providers can submit initial prior authorization requests for certain back, joint and pain management procedures.
If the CPT code entered requires authorization, the user can go through the medical necessity review process using InterQual subsets (formerly called SmartSheets). If criteria are met and the member’s eligibility is active, the authorization will be approved automatically. If not, the authorization will "pend" for your review and you’ll be notified.