Using InterQual^® Decision Reasons

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Note: Decision Reasons content is available as a content add-on module and will be available only if your organization licenses it.

Decision Reasons helps primary and secondary reviewers, case managers, medical directors, and others author consistent communications to members and providers that include clear and specific clinical reasons for decisions regarding medical necessity. In the medical review workflow, this decision is typically made after the secondary review process is completed.

Each organization must determine how to incorporate Decision Reasons into their utilization management (UM) workflow. To increase efficiency, the primary reviewer can select Decision Reasons before referring the case for secondary review. Alternatively, the secondary medical reviewer can select Decision Reasons once secondary review is completed. The functionality for selecting Decision Reasons is the same for both primary and secondary review.

You access Decision Reasons from the Medical Review screen for decision-tree criteria or, if you are using Q&A criteria, from the Recommendations screen. You select the appropriate Decision Reasons based on the patient’s clinical information and the medical review. Depending on the information that is received, it may be appropriate to select more than one reason.

When using decision-tree criteria, Decision Reasons can include a provider-level section that is generated based on criteria points marked as Not Met during the medical review. When Decision Reasons content is selected and one or more criteria points (or rules) are marked as Not Met, the system generates provider-focused content that shows the specific Not Met criteria and supports the determination. Like member-level content, this provider-level content is included in the Review Summary and other outputs and is intended to support clear, clinically specific communication with providers.

Note: Book View provides view-only access to Decision Reasons.

Use Decision Reasons in a decision-tree review

After you select a subset and evaluate criteria, you use Decision Reasons as follows:

• Select Decision Reasons.

  The Decision Reasons content includes a patient education statement that introduces the clinical scenario, including the requested level of care.

• Select a plus sign to expand a Decision Reasons section and select a minus sign to collapse it.
• Select a Decision Reason. Selected Decision Reasons change to green and have a check mark.

Note: Selecting a top-level Decision Reason will also select the children. Alternatively, you can select each Decision Reason individually.

• When you have finished selecting Decision Reasons, select MEDICAL REVIEW COMPLETED .
• Continue with Viewing and Printing the Review Summary where you view and copy the selected Decision Reasons information and paste it into your member or provider communication.

Use Decision Reasons in a Q&A review

After you select a subset and evaluate criteria, you use Decision Reasons as follows:

• From the Recommendations screen, select Decision Reasons.

  The Decision Reasons content includes a patient education statement that introduces the clinical scenario.

• Select a plus sign to expand a Decision Reasons section and select a minus sign to collapse it.
• Select a Decision Reason. Selected Decision Reasons change to green and have a check mark.

Note: Selecting a top-level Decision Reason will also select the children. Alternatively, you can select each Decision Reason individually.

• When you have finished selecting Decision Reasons, select Review Summary.
• Continue with Viewing and Printing the Review Summary where you view and copy the selected Decision Reasons information and paste it into your member or provider communication.