We’ll use updated 2023 InterQual criteria, starting Feb. 1

On Feb. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will start using updated 2023 InterQual^® criteria to make determinations on prior authorization requests for the services we manage.

Change Healthcare published updates to its 2023 InterQual criteria on Oct. 6, 2023. Refer to the table below to see which updated criteria we’re adopting. When you open the documents linked below, you’ll see the changes in red.

How we’ll use the updated criteria

We’ll use the updated criteria to make determinations on prior authorization requests for non-behavioral health services 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 providers to submit specific components of the medical record that show that the request meets the criteria. We review this information when making determinations on prior authorization requests.

This information:

• Applies to lines of business and members whose authorizations are managed by Blue Cross or BCN directly and not by independent companies that provide services to Blue Cross Blue Shield of Michigan
• Doesn’t apply to behavioral health services

No updates to our local rules

We’re not updating our local rules. We use InterQual criteria and our local rules when making determinations on prior authorization requests for Blue Cross and BCN commercial members for these types of post-acute care:

• Skilled nursing
• Inpatient rehabilitation
• Long-term acute care

You can access the local rules for post-acute care as follows:

• On the Blue Cross Authorization Requirements & Criteria page of ereferrals.bcbsm.com. Look in both the Blue Cross commercial and the Medicare Plus Blue sections of that page.
• On the BCN Authorization Requirements & Criteria page of ereferrals.bcbsm.com. Look under the Referral and authorization information heading.

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