InterQual® Criteria Products

Each criteria product can work independently or with other criteria sets. These products help the reviewer determine the appropriateness of patient care across a range of settings.

Criteria products are organized into product families as follows:

Level of Care Criteria include the following products:

  • Acute (Adult and Pediatric): Provides evidence-based clinical decision support for determining the medical appropriateness of hospital admission, continued stay, and discharge. Adult criteria are for review of patients ≥ 18 years of age. Pediatric criteria are for review of patients < 18 years of age.
  • Home Care: Provides healthcare organizations with evidence-based clinical decision support for determining the appropriateness of initial and ongoing home care services. The InterQual® Private Duty Nursing (PDN) Assessment provides healthcare organizations with a comprehensive assessment for determining a maximum number of private duty nursing hours recommended on a daily or weekly basis. Healthcare providers and reviewers use the criteria, and the assessment with suggested hours, to make effective utilization decisions at the point of care or during the preauthorization process.
  • Long-Term Acute Care: Provides evidence-based clinical decision support for determining the appropriateness of Long-Term Acute Care (LTAC) admission, continued stay, and discharge destinations for patients who are 18 years of age and older.
  • Outpatient Rehabilitation & Chiropractic: Provides evidence-based clinical decision support for decisions about the appropriateness of therapy services and chiropractic care in the outpatient setting.
  • Inpatient Rehabilitation: Provides evidence-based clinical decision support for determining the appropriateness of admission, continued stay, and discharge destinations for rehab patients. The Acute Adult Rehabilitation Criteria and Subacute Rehabilitation Criteria are for adult patients 18 years of age and older. The Pediatric Rehabilitation Criteria are for children younger than 18 years of age.
  • Subacute & Skilled Nursing: Provides evidence-based clinical decision support for determining the appropriateness of admission, continued stay, and discharge destination. Adult criteria are for review of patients 18 years of age and older. Pediatric criteria are for review of patients younger than 18 years of age.

Behavioral Health Criteria include the following products:

  • Adult and Geriatric Psychiatry: Provides evidence-based clinical decision support for predetermining the medical appropriateness of the current or proposed level of care. Includes levels of care such as Inpatient, Observation, and Residential Crisis Program.
  • Child and Adolescent Psychiatry: Provides evidence-based clinical decision support for predetermining the medical appropriateness of the current or proposed level of care. Includes levels of care such as Inpatient, Observation, and Partial Hospital Program.
  • Behavioral Health Services: Provides evidence-based clinical decision support for behavioral related procedures or services. The review is independent of level of care and can be performed in any treatment setting.
  • Substance Use Disorders: Provides evidence-based clinical decision support for determining the clinical appropriateness of the current or proposed level of care. Includes levels of care such as Inpatient, Inpatient Detoxification, Supervised Living, and Partial Hospital Program.

Ambulatory Care Planning Criteria include the following products:

  • Durable Medical Equipment: Provides evidence-based clinical decision support for determining the appropriateness of a piece of durable medical equipment.
  • Imaging: Provides evidence-based clinical decision support for imaging studies.
  • Molecular Diagnostics: Provides evidence-based clinical decision support for molecular and genetic tests.
  • Procedures: Provides evidence-based clinical decision support for procedures.
  • Retrospective Monitoring: Provides evidence-based retrospective monitoring support for medical procedures.
  • Specialty Referral: Provides evidence-based clinical decision support for referral to specialists.
  • Specialty Rx Non-Oncology: Provides evidence-based clinical decision support for specialty pharmacy non-oncology medications.
  • Specialty Rx Oncology: Provides evidence-based clinical decision support for specialty pharmacy oncology medications.

Provides healthcare organizations with clinical decision support that is aligned with the Medicare National, Local Coverage Determinations and select Articles (NCDs, LCDs and Articles). Healthcare providers and reviewers use the criteria to make effective utilization decisions at the point of care or during the preauthorization process. The following products are included:

  • Medicare Behavioral Health Navigator
  • Medicare Post Acute & Durable Medical Equipment Navigator
  • Medicare Imaging Navigator
  • Medicare Molecular Diagnostics & Lab Navigator
  • Medicare Pharmacy Navigator
  • Medicare Procedures Navigator

The Concert Genetics Navigator solution provides Concert’s evidence-based coverage criteria and comprehensive GTU™ test identification system integrated seamlessly into your existing InterQual workflow to enable efficient, evidence-based decisions in the fast-growing precision medicine space.

The ASAM Criteria®Navigator1 provides healthcare organizations with clinical decision support consistent with The American Society of Addiction Medicine’s The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. The ASAM Criteria Navigator helps determine the appropriateness of admission, transfer, and continued stay. The criteria are for review of Adult patients 18 years of age and older, and for Adolescent patients ages 13 to 17 years for addiction and co-occurring conditions. Healthcare providers and reviewers use the criteria to make effective utilization decisions at the point of care or during the preauthorization process.

1The ASAM Criteria is a registered trademark of the American Society of Addiction Medicine. 

A Clinical Evidence Summary (CES) is a narrative pertaining to the clinical evidence supporting a specific molecular or genetic test family under review. Although a medical review with questions and answers may not be available for each test, a CES may be available for some subsets specific to molecular testing.