InterQual Level of Care criteria

The InterQual^® Level of Care products cover the continuum of care. The richness of clinical detail allows for consideration of an individual patient's severity of illness, comorbidities, and complications in the review process in real time. InterQual criteria sets for inpatient rehabilitation, subacute and skilled nursing facilities contain objective endpoints for service, allowing case managers to perform reviews of discharge or transfer readiness with built-in checkpoints to identify progress, plateau or achievement of goals. Because all of our level-of-care criteria sets support decisions based on the individual's clinical needs, the clinical review process guides the reviewer toward the safest and most efficient level.

Priority Health has adopted the following criteria:

• InterQual Long-Term Acute criteria
• InterQual Rehabilitation criteria
• InterQual Subacute & Skilled Nursing Facility criteria

The InterQual criteria are used by the medical case managers when conducting inpatient utilization review. InterQual criteria are clinically based on best practice, clinical data and medical literature. The criteria are updated continually and released annually.    

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 case manager. If the criteria are met, the case is approved; if the criteria are not met, the case is referred to the associate vice president of medical affairs and/or a medical director. InterQual criteria cannot be used to deny a case. Only physicians can determine clinical appropriateness.

Priority Health also recognizes that the criteria can never address all the issues; criteria cannot apply to every patient in every situation. Use of the criteria never replaces clinical judgment.

The InterQual Level of Care criteria will be reviewed and approved annually by the associate vice president of medical affairs and the Medical Affairs Committee.