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July 2020
2020 InterQual® criteria to be implemented Aug. 1
Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2020 InterQual criteria on Aug. 1, 2020, to make utilization management determinations. There is InterQual criteria for behavioral health services, as well as non-behavioral health services. However, for Blue Cross commercial members, New Directions, an independent company that provides behavioral health services for most Blue Cross members, uses its own criteria for making determinations.
Non-behavioral health services
We’ll use updated criteria for all levels of care to make utilization management determinations for requests to authorize non-behavioral health services, subject to review, for the following members:
- Blue Cross commercial
- Medicare Plus BlueSM
- BCN 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 2020 local rules will also go into effect on Aug. 1, 2020.
You’ll be able to access the updated versions of the modifications (local rules), as applicable, for [Note to reviewers – updated criteria will be posted by June 26]:
- 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 Blue Cross’ PPO and the Medicare Plus Blue PPO sections of that page. You can also find the 2020 InterQual criteria by the end of July within Provider Secured Services. After you log in, click 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
|
| InterQual level of care — Subacute and skilled nursing facility |
- Subacute and skilled nursing facility admissions
- Continued stay discharge readiness
|
| InterQual rehabilitation — Adult and pediatrics |
- Inpatient admissions
- Continued stay and discharge readiness
|
| InterQual level of care — Long-term acute care |
- Long-term acute care facility admissions
- Continued stay discharge readiness
|
| InterQual level of care — Home care |
Home care requests |
| InterQual imaging |
Imaging studies and X-rays |
| InterQual procedures — Adult and pediatrics |
Surgery and invasive procedures |
| Medicare coverage guidelines (as applicable) |
Services that require clinical review for medical necessity and benefit determinations |
| Blue Cross and BCN medical policies |
Services that require clinical review for medical necessity |
| BCN-developed local rules (applies to BCN commercial and BCN Advantage) |
Exceptions to the application of InterQual criteria that reflect BCN’s accepted practice standards |
Note: The information in the table above 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.
Behavioral health services
BCN commercial, BCN AdvantageSM and Medicare Plus BlueSM will begin using the 2020 InterQual® criteria for behavioral health utilization management determinations on Aug. 1.
In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below.
| Line of business |
Modified 2020 InterQual criteria for: |
Local rules or medical policies for: |
BCN commercial
BCN Advantage
Medicare Plus Blue
|
- Substance use disorders: Partial hospital program and intensive outpatient program.
- Mental health disorders: Partial hospital program and intensive outpatient program.
- Residential mental health treatment (adult/geriatric and child/adolescent)
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- Autism spectrum disorder/applied behavior analysis (for BCN commercial only).
- Neurofeedback for attention deficit disorder/attention deficit hyperactivity disorder
- Transcranial magnetic stimulation
- Telemedicine (telepsychiatry/teletherapy)
|
- Substance use disorders: Partial hospital program and intensive outpatient program.
- Mental health disorders: Partial hospital program and intensive outpatient program.
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Links to the updated versions of the modified criteria, local rules and medical policies will be available on the Blue Cross Behavioral Health page and the BCN Behavioral Health page at ereferrals.bcbsm.com.
As noted earlier in this article, determinations for behavioral health services for Blue Cross commercial members are handled by New Directions, an independent company that provides behavioral health services for most Blue Cross members. New Directions uses its own Medical Necessity Criteria. |
