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Changes to our InterQual page
May 8, 2021

This article is for all providers (excluding dentists) caring for our members

To help us share our claims decision-making criteria with you as soon as we make updates, we have changed the way you access InterQual® criteria on our website. The Level of Care Criteria Application (also called the InterQual Transparency Tool) on the page is now hosted by Change Healthcare.

We use InterQual criteria for decisions involving:
  • medical and behavioral health inpatient levels of care and residential treatment
  • intermediate levels of care such as intensive outpatient program
  • outpatient services such as homecare, outpatient rehabilitation, neuropsychological testing, and Applied Behavior Analysis

We also use InterQual criteria for select surgical procedures such as spine, hysterectomies, and hip and knee replacements.

In addition, we moved the InterQual Criteria & SmartSheet page to the Clinical Resources>Coverage Criteria and Guidelines section on our website.

To access the Transparency Tool, log in and go to Clinical Resources>Coverage Criteria and Guidelines>InterQual Criteria & SmartSheets. Then click Go Now.

Note: You must enable cookies on your browser.

To view, download, or print InterQual criteria:

  1. Search for a Subset (for example, “Asthma,”) by keyword or code.
    Click Find Subsets.

  2. Double-click the name of the Subset to open the Notes view.

  3. To access the InterQual criteria, click the Book View button at the bottom of the screen. You can print a SmartSheet to use for requesting authorization if you also see a Print Full Subset button. SmartSheets are available for hysterectomies, hip/knee replacements, and certain back surgeries.

The criteria included in the Transparency Tool appear in these Change Healthcare products:

Medical/surgical products Behavioral health products
LOC: Acute Adult
LOC: Acute Pediatric
LOC: Long-Term Acute Care
LOC: Rehabilitation
LOC: Subacute/SNF
LOC: Home Care Q&A
LOC: Outpatient Rehabilitation*
CP: Procedures
BH: Adult and Geriatric Psychiatry
BH: Child and Adolescent Psychiatry
BH: Procedures Q & A
BH: Substance Use Disorders

* excluding chiropractic


 Authorization Quick Tip