What are InterQual guidelines?

12/14/2019 Off By admin

What are InterQual guidelines?

InterQual® criteria are a first-level screening tool to assist in determining if the proposed services are clinically indicated and provided in the appropriate level or whether further evaluation is required. The first-level screening is done by the utilization review nurse.

How do I get an InterQual criteria?

Viewing the InterQual criteria To help you understand determinations based on the InterQual clinical criteria, we give you access to a read-only version of the criteria at UHCprovider.com/policies > Clinical Guidelines > InterQual Clinical Criteria.

What is InterQual medical necessity criteria?

Support medical necessity decisions Assess the safest, most efficient care level by using objective, specific criteria based on severity of illness, comorbidities, complications, and the intensity of services delivered.

What are behavioral health settings?

The three primary types of treatment settings for receiving mental health care or services are 1) hospital inpatient, 2) residential and 3) outpatient. In addition, some mental health care services are delivered via online and telecommunications technologies.

What is Milliman or InterQual?

MCG focuses more on severity of illness and diagnosis. InterQual focuses more on intensity of service required and provides detailed day-by-day guidelines.

What is the difference between InterQual and Milliman?

InterQual’s criteria are, in some respects, stricter than Milliman’s, with more precise clinical benchmarks for each level of care. That could mean an uptick in denials for cases in which the patient is borderline for inpatient vs. observation or discharge vs. continued stay.

What is the difference between Milliman and InterQual?

Does Medicare use InterQual criteria?

Does Medicare/CMS (Centers for Medicare and Medicaid Services) care about Milliman or InterQual criteria? CMS recommends admission guidelines as one of many factors to consider when making an admission decision, but it does not endorse any particular criteria or assign specific authority to them.

Does CMS use InterQual or Milliman?

Notably, the Centers for Medicare and Medicaid Services (CMS), has declined to adopt a proprietary decision support tool like Milliman or InterQual, hewing instead to a broader definition of medical necessity.

Is behavioral health the same as mental health?

Behavioral health refers to how our daily cognitive habits affect our overall well-being, emotions, biology, and behavior. It’s often used interchangeably with mental health, but is actually a far more expansive term that incorporates not just our mental wellness, but the way our thoughts play out in real life.

What are examples of behavioral health?

Behavioral health is the way your habits impact your mental and physical wellbeing. That includes factors like eating and drinking habits, exercise, and addictive behavior patterns. Substance abuse, eating disorders, gambling and sex addiction are all examples of behavioral health disorders.

What insurance companies use InterQual?

Companies Currently Using InterQual

Company Name Website Sub Level Industry
Unitedhealth Group unitedhealthgroup.com Insurance & Managed Care
CHRISTUS Health christushealth.org Hospitals & Clinics
Providence Health & Services standardlife.com Insurance
Humana aetna.com Insurance & Managed Care