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July 2022

2022 InterQual criteria to be implemented Aug. 1

Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2022 InterQual® criteria on Aug. 1, 2022, 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, New Directions® Behavioral Health, an independent company that managers authorizations for behavioral health and autism services for most Blue Cross commercial 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 2022 local rules for acute care inpatient medical admissions were implemented on March 1, 2022. The 2022 local rules for post-acute care will be announced at a later date.

You can access 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 commercial and Medicare Plus Blue sections of that page.
  • 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 about which criteria are used in making determinations for various types of non-behavioral health authorization requests.

Criteria

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 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

    Modifications of InterQual for acute medical admissions of adults (condition-specific local rules)  
  • Exceptions to the application of InterQual criteria that reflect the accepted practice standards for Blue Cross and BCN

    Local rules for post-acute care (applies to inpatient rehabilitation, skilled nursing facility and long-term acute care admissions for Blue Cross commercial and BCN commercial)
  • Exceptions to the application of InterQual criteria that reflect the accepted practice standards for Blue Cross and BCN

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. 1, 2022, we’ll begin using the 2022 InterQual criteria to make utilization management determinations for behavioral health services for these members:

  • 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.

Health plans

Modified InterQual criteria for:

Local rules or medical policies for:

BCN commercial and BCN Advantage
  • 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, child and adolescent members)

Note: Neither BCN commercial members with BCN1, BCN5 and BCN10 plans nor BCN Advantage members have residential mental health treatment benefits.
  • Applied behavior analysis for autism spectrum disorder — for BCN commercial members only
  • Neurofeedback for attention deficit disorder and attention deficit hyperactivity disorder
  • Transcranial magnetic stimulation, or TMS
  • Telemedicine (telepsychiatry and teletherapy)

Medicare Plus Blue

  • Substance use disorders: partial hospital program and intensive outpatient program
  • Mental health disorders: partial hospital program and intensive outpatient program

Note: Only State of Michigan Medicare Plus Blue members have intensive outpatient program benefits.
  • Telemedicine (telepsychiatry and teletherapy)

Note: Medicare Plus Blue members don’t have neurofeedback or TMS benefits.

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 behavioral health and autism local rules and to the medical policies. Those links will be located on these pages on our ereferrals.bcbsm.com website:

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.**

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

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 2021 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.