InterQual® ISD criteria for medical decision-making

InterQual® ISD criteria are used by the utilization review nurses when conducting inpatient utilization reviews. Priority Health chose InterQual® ISD criteria based on requests from providers and because all of our contracted acute care facilities use InterQual® ISD criteria.

InterQual® ISD criteria are clinically based on best practice, clinical data, and medical literature. The criteria are updated continually and released annually. Decisions made by using InterQual® ISD criteria are based on each patient's clinical status and relies on patient-specific clinical indicators, service requirements, and discharge/transfer readiness. InterQual® ISD 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. 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 the medical director. InterQual® ISD criteria cannot be used to deny a case. Only physicians can determine clinical appropriateness.

Priority Health also recognizes that the criteria can never address all the issues; criteria cannot apply to every patient in every situation. Use of the criteria never replaces clinical judgment.

The InterQual® ISD criteria are reviewed and approved annually by the associate vice president of medical affairs and the Medical Affairs Committee.