InterQual® CP criteria for medical decision-making

InterQual® CP criteria are used by the Authorization team to assist them in determining coverage for procedures including surgeries, invasive procedures, equipment and molecular diagnostic testing. Priority Health chose InterQual® CP criteria to ensure decision-making consistency and medical necessity.

InterQual® CP criteria are a first level screening tool to assist in determining if the proposed procedure, equipment or molecular diagnostic testing is clinically indicated or whether further evaluation is required. The first level screening is done by the 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® CP criteria cannot be used to deny procedures, equipment or testing. Only physicians can determine clinical appropriateness.

Priority Health has adopted the following criteria: 

  • InterQual® CP Procedures
  • InterQual® CP Durable Medical Equipment 
  • InterQual® Medicare Durable Medical Equipment
  • InterQual® Medicare Procedures

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® CP criteria are reviewed and approved annually by the medical director and the Medical Affairs Committee.