July 2023

We’ll use 2023 InterQual criteria, starting Aug. 1

Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2023 InterQual^® criteria to make determinations on prior authorization requests for the behavioral and nonbehavioral health services we manage, starting Aug. 1, 2023.

The information below 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.

Nonbehavioral health services

We’ll use updated criteria for all levels of care to make determinations on prior authorization requests for nonbehavioral 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.

Blue Cross and BCN also use local rules, which are modifications of InterQual criteria, in making determinations. You can access these rules 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.

Refer to the table below for more specific information about which criteria we use in making determinations for various types of nonbehavioral health prior authorization requests.

Starting Aug. 1, we’ll no longer use the condition-specific local rules for acute inpatient medical admissions.

Criteria	Services
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
Local rules for post-acute care (apply 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

Behavioral health services

On Aug. 1, 2023, we’ll begin using the 2023 InterQual criteria to make determinations on prior authorization requests for behavioral health services for these members:

Medicare Plus Blue
BCN commercial
BCN Advantage

In addition, certain determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below.

Products

Modified InterQual criteria for:

Local rules or medical policies for:

BCN commercial and BCN Advantage

Mental health disorders: partial hospital 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
Neurofeedback for attention deficit disorder and attention deficit hyperactivity disorder
Transcranial magnetic stimulation, or TMS
Telemedicine (telepsychiatry and teletherapy)

Medicare Plus Blue

Mental health disorders: partial hospital program

Telemedicine (telepsychiatry and teletherapy)

You can find links to the current modified behavioral health and autism local rules, as well as instructions for accessing the medical policies, on these webpages:

We’ll update these pages before Aug. 1 to reflect the criteria changes.

Note: Determinations on Blue Cross commercial behavioral health authorization requests are handled by New Directions Behavioral Health^®. New Directions uses its own medical necessity criteria.

New Directions Behavioral Health is an independent company that manages authorizations for behavioral health and autism services for Blue Cross Blue Shield of Michigan members who have commercial plans.

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 2022 American Medical Association. All rights reserved.