The Record

We’ll use 2025 InterQual criteria starting June 1

For dates of service on or after June 1, 2025, Blue Cross Blue Shield of Michigan and Blue Care Network will use 2025 InterQual^® criteria to make determinations on the prior authorization requests for the medical (nonbehavioral health) services we manage for these members:

Blue Cross commercial

Medicare Plus Blue℠

BCN commercial

BCN Advantage℠

Note: If the InterQual criteria are updated to correct known issues or errors, we’ll use the updated criteria as soon as they’re available.

For Blue Cross and BCN commercial members, we also use Local Rules when making determinations on post-acute care (inpatient rehabilitation, skilled nursing facility and long-term acute care) prior authorization requests. These Local Rules are modifications of InterQual criteria that we use in making determinations. You can access the Local Rules on the Services That Need Prior Authorization page on bcbsm.com.

We’ll update that page to include the most current version of the Local Rules.

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

Criteria

Services

InterQual level of care — Adult and acute 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 level of care— Inpatient 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

BCN Advantage medical policies

Services that require clinical review for medical necessity but for which there isn’t applicable Centers for Medicare & Medicaid Services guidance

Local Rules — Exceptions to the application of InterQual criteria that reflect the accepted practice standards for Blue Cross and BCN

Post-acute care (applies to inpatient rehabilitation, skilled nursing facility and long-term acute care admissions for Blue Cross commercial and BCN commercial)

When clinical information is requested for a medical or surgical admission or other services, we require providers to submit specific components of the medical record that show the request meets the criteria. We review this information when making determinations on prior authorization requests.

Note: The information in this article applies to members whose authorizations are managed by Blue Cross or BCN directly and not by independent companies that provide services to Blue Cross or BCN.

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 2024 American Medical Association. All rights reserved.