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July 2015

Blue Cross to implement 2015 InterQual® criteria Aug. 3

Submitting comments to InterQual® Criteria Helpline

If you have questions, concerns or comments about InterQual® criteria, email Blue Cross at InterQualCriteria@bcbsm.com.

So we can respond to you accurately and quickly by email, provide the following information when emailing your questions:

  • Criteria book you are using
  • Page number from that book
  • Criteria you have a question about
  • Your question, comment or concern

Example of how to format a question:

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

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

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

Blue Cross Blue Shield of Michigan will implement 2015 InterQual acute care, rehabilitation, skilled nursing, long-term acute care and home health criteria, starting Aug. 3, 2015. The criteria format for rehabilitation, skilled nursing, long-term acute care and home care criteria haven’t changed.

This year, there are still 32 adult and 24 pediatric acute care criteria for specific conditions. General medical and surgical categories will remain in their previous format for patients who don’t fall within a condition-specific subset.

The acute care criteria transition plan section lists conditions associated with a high risk of readmissions. This information can be useful in determining which patients to refer to our case management department.

The acute care quality indicators section lists the quality indicators for improving the quality of hospital care. The National Quality Forum developed these national standard indicators.

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

Blue Cross modifications, or local rules, of InterQual criteria were published on web-DENIS in June. To access them:

  1. Log in to web-DENIS.
  2. Click on BCBSM Provider Publications and Resources in the left 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.
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 2014 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.