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July 2019
2019 InterQual® criteria to be implemented Aug. 1 for non-behavioral health determinations
Blue Cross Blue Shield of Michigan and Blue Care Network will start using the 2019 InterQual criteria on Aug. 1, 2019, for all levels of care. We’ll use these criteria to make utilization management determinations for requests to authorize non-behavioral health services subject to review for the following members:
- Blue Cross PPO (commercial)
- Blue Cross Medicare Plus BlueSM PPO
- BCN HMOSM (commercial)
- BCN AdvantageSM
When clinical information is requested for a medical or surgical admission or for other services, we require submission of the specific components of the medical record that validate that the request meets the criteria.
Blue Cross and BCN also use local rules — modifications of InterQual criteria — in making utilization management determinations. The 2019 local rules will also go into effect on Aug. 1, 2019.
By the end of July, you’ll be able to access the updated versions of the modifications (local rules), as applicable, for:
- Blue Cross — on the Authorization Requirements & Criteria page in the Blue Cross section of our ereferrals.bcbsm.com website. You’ll see links to the criteria in both the Blue Cross PPO and the Medicare Plus Blue PPO sections of that page. You can also find the 2019 InterQual criteria by the end of July within BCBSM Provider Publications and Resources. Click Newsletters & Resources, click Clinical Criteria & Resources and scroll down to the section titled BCBSM modifications to InterQual criteria.
- BCN — on the Authorization Requirements & Criteria page in the BCN section of our ereferrals.bcbsm.com website. Look under the Referral and authorization information heading.
Refer to the table below for more specific information on which criteria are used in making determinations for various types of non-behavioral health authorization requests.
| Criteria/version |
Application |
| InterQual Acute — Adult and Pediatrics |
- Inpatient admissions
- Continued stay discharge readiness
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| InterQual Level of Care — Subacute and Skilled Nursing Facility |
- Subacute and skilled nursing facility admissions
- Continued stay discharge readiness
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| InterQual Rehabilitation — Adult and Pediatrics |
- Inpatient admissions
- Continued stay and discharge readiness
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| InterQual Level of Care — Long Term Acute Care |
- Long-term acute care facility admissions
- Continued stay discharge readiness
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| InterQual Level of Care — Home Care |
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| InterQual Imaging |
- Imaging studies and X-rays
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| InterQual Procedures — Adult and Pediatrics |
- Surgery and invasive procedures
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| Medicare Coverage Guidelines (as applicable) |
- Services that require clinical review for medical necessity and benefit determinations
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| Blue Cross/BCN medical policies |
- Services that require clinical review for medical necessity
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| BCN-developed Local Rules (applies to BCN HMO and BCN Advantage) |
- Exceptions to the application of InterQual criteria that reflect BCN’s accepted practice standards
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Note: The information in the table applies to lines of business and members whose authorizations are managed by Blue Cross or BCN directly and not by an independent company that provides services to Blue Cross Blue Shield of Michigan.
InterQual criteria for behavioral health
See the article titled We’re using updated utilization management criteria for behavioral health for information on the updated behavioral health criteria we’ll use starting Aug. 1, 2019.
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