2021 InterQual^® criteria to be implemented Aug. 2

Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2021 InterQual criteria on Aug. 2, 2021, to make utilization management determinations.

Keep in mind that there are 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 manages behavioral health services for most Blue Cross members, uses its own criteria for making determinations on behavioral health authorization requests.

Additional information about behavioral health services is at the end of this article.

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 Blue℠
• BCN commercial
• BCN Advantage℠

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 2021 local rules will also go into effect on Aug. 2, 2021.

In early 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 Blue Cross commercial and the Medicare Plus Blue sections of that page. You’ll also be able to find it in Provider Secured Services. After you log in, click on BCBSM Provider Publications and Resources. Click on Newsletters & Resources, click on 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.

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

On Aug. 2, 2021, we’ll begin using the 2021 InterQual^® criteria to make utilization management determinations for behavioral health services for members with:

• Medicare Plus Blue
• BCN commercial
• BCN Advantage

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.

For more information on telemedicine, refer to the Blue Cross and BCN: Telehealth for behavioral health providers document.

In early July, we’ll have links to the updated versions of the modified criteria, local rules and medical policies on these pages on our ereferrals.bcbsm.com website:

• Blue Cross Behavioral Health page
• BCN Behavioral Health page
• BCN Autism page

As noted earlier in the article, determinations on Blue Cross commercial behavioral health authorization requests are handled by New Directions. New Directions uses its own Medical Necessity Criteria.