InterQual® LOC criteria for medical decision-making

The InterQual® Level of Care products cover the continuum of medical 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 acute adult, acute pediatric, inpatient rehabilitation, and subacute skilled nursing facilities contain objective endpoints for service, allowing utilization review nurses to perform reviews of admission, 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® LOC Acute Adult
  • InterQual® LOC AcutePediatric
  • InterQual® LOC Long-Term Acute criteria
  • InterQual® LOC Rehabilitation criteria
  • InterQual® LOC Subacute & Skilled Nursing Facility criteria
  • InterQual® LOC Home Care Services criteria

The InterQual® criteria are used by the utilization review nurses when conducting inpatient and post-acute 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 utilization review nurse. 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.

Priority Health chose InterQual® LOC criteria based on requests from providers and because all of our contracted care facilities use InterQual® LOC criteria.