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July 2014

2014 InterQual® criteria implemented Aug. 4

Here’s how to submit comments to InterQual® Criteria Helpline

If you have questions, concerns or comments about InterQual® criteria, email Blue Cross Blue Shield of Michigan at InterQualCriteria@bcbsm.com. We will respond by email.

In order for us respond to you accurately and quickly, provide the following information when emailing your questions:

  • Indicate which criteria book you are using.
  • Indicate the page number from that book.
  • Reference which criterion or criteria you have a question about.
  • Write your actual question, comment or concern.

For example:

Under “Acute Criteria, Adult” on Page ADLT-13 Acute Coronary Syndrome, INTERMEDIATE, Intervention: Do the newer oral anticoagulants alone meet this criterion?

Be sure to include your name and your organization’s name.

As a reminder, the telephone-based InterQual Criteria Helpline transitioned to email format several years ago. 

Blue Cross Blue Shield of Michigan will implement InterQual acute care, rehabilitation, skilled nursing, long-term acute care and home health criteria, effective Aug. 4, 2014. The format for rehabilitation, skilled nursing, long term acute care and home care criteria have not changed.

In 2014, InterQual increased its condition-specific subsets to 32 adult and 25 pediatric acute care criteria. General medical and surgical subsets remain in their customary format as in previous years for those patients who are not in the condition-specific subsets.

The Transition Plan section of the acute care criteria lists conditions associated with high risk of readmissions and an opportunity to refer your patients to our case management department.

The acute care Quality Indicators section lists the quality indicators for improving the quality of hospital care. These indicators are the national standard sets developed by the National Quality Forum.

InterQual criteria should be applied to all elective or emergency hospital admissions.

The BCBSM modifications, or local rules, of the InterQual criteria were published on web-DENIS in late May. To access them:

  1. Log in to web-DENIS.
  2. Click on BCBSM Provider Publications and Resources in the left-hand column.
  3. Click on Newsletters and Resources in the left column or at the top of the page.
  4. Click on Clinical Criteria and Other Resources.

BCBSM will only offer comprehensive InterQual training webinars this year. Schedules for the webinars will be published in The Record and posted to web-DENIS.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.
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