Starting May 6, 2019, InterQual will replace observation local rules
Based on your feedback, we're making changes to our utilization management program to better serve you while ensuring our members are getting the right care, at the right place, at the right time and at the right price.
On May 6, we'll begin using InterQual® 2018.3 criteria which include observation subsets instead of our local rules to identify observation appropriate care when an urgent/emergent hospital authorization is requested. InterQual criteria will be used for all of our products and addresses many of the local rules conditions we identified as appropriate for observation level of care.
Why InterQual and what are the conditions?
InterQual is nationally recognized as an industry standard for evidence-based medicine criteria. Although InterQual has observation level of care criteria for several subsets, the following have criteria that require failed observation of either 24 or 48 hours before acute level of care application. Additional subsets will be updated in the 2019 annual release.
- Acute Coronary Syndrome
- Deep Vein Thrombosis
- Heart Failure*
- Pulmonary Embolism (low risk)
- Transient Ischemic Attack
*Represents 48 hours failed observation.
Plan types affected
Authorization for inpatient admission is required for all Priority Health product lines, including commercial group and individual plans, Medicare and Medicaid.
How we determine medical necessity
View our utilization management program criteria for more details on how we evaluate medical necessity and appropriateness of care.
How to submit or edit your inpatient request
How to submit a retroactive request
There’s no change to our retroactive requests. You continue to submit the request via fax.
Note: Medicare does not allow retrospective requests for authorization. Providers should submit a claim and appeal for payment.