Evaluating criteria in a medical review

During a medical review, you evaluate criteria to help determine the medical appropriateness of proposed services.

After you select a subset, you evaluate criteria in a medical review. Depending on the product you select, the medical review is available in either decision-tree format or question-and-answer (Q&A) format.

Evaluate decision-tree criteria

(Optional) See the following additional tasks you can perform as you evaluate criteria:

Look up information in the Clinical Reference

Select to see a list of resources (for example, clinical revisions, criteria bibliographies, review process, and other supporting materials).
Select a resource to view it.
For PDFs, depending on the options available, select Open or Download PDF and use the controls in the PDF to save and/or print the document.

Add, edit, and delete reviewer comments

Add reviewer comments

As you evaluate criteria, you can add comments to the review or to specific criteria points. Comments have a 4,000 character limit.

Select Comments to add a comment to the review or select the appropriate comments icon for a criteria point.

The Reviewer Comments dialog appears.

Enter your comment in the text box.
Select Add Comment.
Select the X to close the dialog.

When you add a comment to a criteria point, the appearance of the comment icon changes, indicating reviewer comments are associated with the criteria point.

You can view the details of all added comments by selecting Comments. If you added a comment to a criteria point, select Tree Location to view the location of the criteria point within the decision tree.

Edit and delete reviewer comments

You can edit and/or delete comments until the review is completed.

Select Comments to open the Reviewer Comments dialog.
To edit a comment, select the edit icon for the appropriate comment and then type the changes in the text box. Select Done to save your changes.
To delete a comment, select the delete icon for the appropriate comment and then select DELETE in the confirmation message.
Select the X to close the dialog.

Select a utilization benchmark

InterQual content includes benchmarks for length of stay, percent paid as Observation, and Urine Drug Testing. The InterQual benchmark values are derived from a select set of de-identified claims data, representing 7 billion patient encounters. Benchmarks are not intended to serve as treatment limits or substitute for clinical judgment. They are for informational use only.

Benchmark length of stay values are available in the following products:

LOC: Acute Adult and Pediatric Criteria
LOC: Inpatient Rehabilitation Criteria
LOC: Subacute and Skilled Nursing Criteria
BH: Adult and Geriatric Psychiatry, Child and Adolescent Psychiatry, and Substance Use Disorders Criteria

Percent paid as Observation values are available in the LOC: Acute Adult and Pediatric Criteria.

Urine drug testing average annual volumes are available in BH: Behavioral Health Services Criteria and CP: Procedures Criteria.

Select a benchmark:

Select BENCHMARKS.

The Utilization Benchmarks dialog appears.
For Behavioral Health Criteria, if available, select a level of care tab.
If appropriate, find a condition or procedure in the list by entering a partial or complete description.
Select a condition or procedure from the list.

The Benchmarks field is populated with your selection.

View care management information

Available for select subsets, care management information is associated with a specific episode day.

To view care management information:

If closed, select CARE MANAGEMENT to slide out the pane, or select the arrow to open a larger pane that displays in the center of the screen.

Depending on the episode day, the following information appears:

Admission Considerations — identifies the types of clinical findings that should be considered as part of an admission review.
Expected Progress — provides an overall picture of what a care manager should expect in response to treatment, potential barriers to care, and suggested interventions.
Care Facilitation — identifies when a plateau has been reached and provides direction to appropriate post acute levels of care.

When you are done viewing the information, select CLOSE if you are viewing the information in the large pane. If you are viewing the information in the slide out pane, optionally leave it open as you evaluate criteria or slide it back to the side of the screen.

Note: Applies to InterQual^® LOC: Acute Adult and Acute Pediatric, LOC: Long Term Acute Care, LOC: Inpatient Rehabilitation, LOC: Subacute and Skilled Nursing; InterQual^® BH: Adult and Geriatric Psychiatry, BH: Child and Adolescent Psychiatry, BH: Substance Use Disorders; and InterQual^® CP: Retrospective Monitoring and CP: Specialty Referral products.

Select a subset and then select .
Depending on the subset you selected, do the following:

LOC: Acute Adult and Pediatric — select an Episode Day or Initial review.
LOC: Long-Term Acute Care and Inpatient Rehabilitation — select Admission, Continued Stay, or Discharge.
LOC: Subacute & Skilled Nursing — select Preadmission or the appropriate episode week.
BH Adult and Geriatric Psychiatry, BH Child and Adolescent Psychiatry, and Substance Use Disorders — select a level of care and then choose the appropriate episode day or episode week.
CP: Specialty Referral and CP: Retrospective Monitoring — select an indication.

Expand the decision tree as follows:

Select a plus sign to expand a section of the decision tree and select a minus sign to collapse it.
Select Expand All to expand all criteria in the decision tree and select Collapse All to collapse it.
View any notes associated with the criteria by selecting the appropriate note icon:

Informational note — provides reminders of best medical practice, new clinical knowledge, procedural information, explanations of criteria rationale, and current literature references.
Transition Plan note — indicates that the patient might be at a higher risk for readmission and could benefit from comprehensive discharge planning. If you select a criteria point that has a Transition Plan note, Change Healthcare recommends that you complete a transition plan.
Mandatory note — associated with an indication or criteria point, mandatory notes provide important information that you must read while conducting a review.
Care Management note — provides information that helps to drive quality care and ensure that the patient is progressing along the continuum of care.
CMS Two-midnight rule note — provides instructions for the Two-midnight rule.

Select criteria points:

Note: Some criteria points include an "Exclude from Rule Evaluation" icon and a tooltip message that says "Selecting these criteria will not result in the criteria being met."

Select a criteria point. Selected criteria change to green and have a check mark. To return a criteria point to unselected, select it again.
To explicitly indicate that a criteria point is not satisfied, select the Not Met icon (X) on the criteria point . The criteria point changes to red and appears with an X . To return the criteria point to unselected, select the X again.

Note: When supporting documentation does not satisfy criteria, one option is to leave a criteria point unselected. However, explicitly indicating that criteria are not satisfied enables you to make it clear to another reviewer (for example, a secondary reviewer) that you have evaluated the criteria point and determined that the documentation does not satisfy the criteria.
For criteria points that include abbreviations, symbols, or terms with a dotted underline, move the pointer over the underlined item to view the definition of the abbreviation or symbol, or full description of the term. For example, the abbreviation NIPPV is underlined in this criteria point
If you select a criteria point that redirects you to a more appropriate subset that has multiple versions enabled, you are prompted to select a desired version before being redirected.
Use the vertical scroll bar to see all the criteria.

If you select enough criteria points to satisfy criteria rules, the criteria status, which displays in the upper right corner, changes from Criteria Not Met to Criteria Met.

Note: At any time, you can return to a previous screen by selecting Previous or selecting Menu and selecting an option from the navigation pane. You can return to the medical review by selecting Resume Medical Review.
If necessary, at any time, you can select CLEAR ALL to clear all reviewer comments and all your criteria selections, including criteria points you explicitly indicated do not satisfy criteria.

If you select a criteria point that automatically displays a note (for example, a transition plan), read the note and then select OK to close it.

Note: If a note indicates your selection exceeds the limit for these criteria, you must clear a previous selection before you can select the criteria point.

When you have finished selecting criteria, if appropriate, select for a review that did not meet criteria, or go to the Review Summary by selecting .
Continue with Using Decision Reasons or Viewing and printing the Review Summary.

Evaluate Q&A criteria

Note: Applies to InterQual^® LOC: Home Care Q & A and LOC and Outpatient Rehabilitation & Chiropractic; InterQual^® BH: Behavioral Health Services; InterQual^® CP: Durable Medical Equipment, CP: Imaging, CP: Molecular Diagnostics, CP: Procedures, CP: Specialty Rx Non-Oncology, and CP: Specialty Rx Oncology; The ASAM Criteria^®1 Navigator; Concert Genetics Navigator; and Medicare Content Navigator products.

If the InterQual^® CriteriaView feature is available, you can track availability of recommendations as you answer questions and view additional criteria for recommendations that do not meet criteria. For additional overview information, see InterQual^® CriteriaView. For steps on how to use CriteriaView in a review, see Evaluating Criteria using CriteriaView below.

There are two steps to evaluating criteria in a medical review

Answer questions

(Optional) See the following review-related task you might perform as you answer the questions

Look up information in the Clinical Reference

Select to see a list of resources (for example, clinical revisions, criteria bibliographies, review process, and other supporting materials).
Select a resource to view it.
For PDFs, depending on the options available, select Open or Download PDF and use the controls in the PDF to save and/or print the document.

Add, edit, and delete reviewer comments

Add reviewer comments

As you evaluate criteria, you can add comments to the review or to specific criteria points. Comments have a 4,000 character limit.

Select Comments to add a comment to the review or select the appropriate comments icon for a criteria point.

The Reviewer Comments dialog appears.

Enter your comment in the text box.
Select Add Comment.
Select the X to close the dialog.

When you add a comment to a criteria point, the appearance of the comment icon changes, indicating reviewer comments are associated with the criteria point.

You can view the details of all added comments by selecting Comments. If you added a comment to a criteria point, select Tree Location to view the location of the criteria point within the decision tree.

Edit and delete reviewer comments

You can edit and/or delete comments until the review is completed.

Select Comments to open the Reviewer Comments dialog.
To edit a comment, select the edit icon for the appropriate comment and then type the changes in the text box. Select Done to save your changes.
To delete a comment, select the delete icon for the appropriate comment and then select DELETE in the confirmation message.
Select the X to close the dialog.

Note: In Medicare Content Navigator reviews, depending on how your system is configured, the Medicare Administrative Contractor question may be automatically answered.

Select a subset and then select .
Answer the questions by reviewing each one as it appears and providing answers by selecting one or more options, as appropriate.
Follow rules associated with the questions. Rules display in brackets next to the question (for example, [ ≥ One, except Other clinical information (add comment)] is a rule).
If necessary, select Next to continue to the next question. Single answer questions automatically display the next question, while multi-answer questions display the Next button.
View any notes associated with the questions by selecting the note icon.
Answer all required questions. Required questions appear with the word Required in red text next to the question.
When you reach the end of the questions, select .

View and select a recommendation

When the medical review results in one or more recommendations, you select recommendations as follows:

View the recommendation details:
Read any notes by selecting the note icon.
View the ICD, CPT^®,and HCPCS codes that apply by selecting Show Codes. Hide the codes by selecting Hide Codes.
For recommendations that are part of a group, optionally sort the recommendations in alphabetical order.
For Specialty Rx Oncology:
View the NCCN Drugs & Biologics Compendium (NCCN Compendium^®) rating for an off-label drug recommendation.
Optionally, view the NCCN Compendium® rating description by moving the pointer over the rating number.
Optionally, access the National Comprehensive Cancer Network® (NCCN^®) website by selecting the link within the red note.
For Level of Care: Home Care Q & A:
Results might show both Recommended Services and Not Recommended Services. This occurs when you select two or more services and at least one service is recommended and at least one service is not recommended.
Includes the number of visits and, if appropriate, the duration; for example, Physical Therapy – 6 Visits within 2 weeks.
Private Duty Nursing (PDN) Assessment recommendations include a suggested maximum number of private duty nursing hours per day and per week. Recommendations also have a total sum of points based on the selected answer choices. The sum of points falls within a predetermined range of points with the recommendation. The recommendation note provides information about the range of points.
Select a recommendation.

Selected recommendations change to green and automatically display the associated codes.
If benchmark length of stay values are available for a procedure, optionally, select a value:
Select Benchmarks.

The Utilization Benchmarks dialog appears.
If appropriate, find a procedure by entering a partial or complete description in the Indications box.
Select a procedure from the list.

The dialog closes and the selected value appears in the Recommendations screen.
Optionally, select codes:
Select the tab for the type of code you want to select.

Note: If you select ICD codes, you can select either ICD-9 or ICD-10 codes, but not both

Search by medical code or description. Alternately, scroll through the list until you find the code you want.
Select a code. If you want to remove the code, select it again.
View the codes you selected in the Selected tab. The value on the Selected tab reflects the number of codes you selected.
When you have finished selecting recommendations, continue as follows:
If appropriate, select to use Decision Reasons for a review that did not meet criteria.
Select and then continue with Viewing and Printing the Review Summary.

Evaluate criteria using CriteriaView

There are two steps to evaluating criteria in a medical review using CriteriaView

Answer questions

(Optional) See the following review-related tasks you might perform as you answer the questions

Look up information in the Clinical Reference

Select Clinical Reference to see a list of resources (for example, clinical revisions, criteria bibliographies, review process, and other supporting materials).
Select a resource to view it.
For PDFs, depending on the options available, select Open or Download PDF and use the controls in the PDF to save and/or print the document.

Add, edit, and delete reviewer comments

Add reviewer comments

As you evaluate criteria, you can add comments to the review or to specific criteria points. Comments have a 4,000 character limit.

Select Comments to add a comment to the review or select the appropriate comments icon for a criteria point.

The Reviewer Comments dialog appears.

Enter your comment in the text box.
Select Add Comment.
Select the X to close the dialog.

When you add a comment to a criteria point, the appearance of the comment icon changes, indicating reviewer comments are associated with the criteria point.

You can view the details of all added comments by selecting Comments. If you added a comment to a criteria point, select Tree Location to view the location of the criteria point within the decision tree.

Edit and delete reviewer comments

You can edit and/or delete comments until the review is completed.

Select Comments to open the Reviewer Comments dialog.
To edit a comment, select the edit icon for the appropriate comment and then type the changes in the text box. Select Done to save your changes.
To delete a comment, select the delete icon for the appropriate comment and then select DELETE in the confirmation message.
Select the X to close the dialog.

Note: If the CriteriaView feature is not available, follow the directions in the Evaluate Q&A criteria above.

Select a subset and then select .
Optionally, select recommendations you want to track:
Select CriteriaView on the right side of the screen to display the CriteriaView pane. Hide the pane at any time by selecting CriteriaView again or, optionally, leave it open as you answer the questions.

The CriteriaView pane displays a list of recommendations for the subset.
Select to track all recommendations or select the check box(es) to track specific recommendation(s).
Answer the questions by reviewing each one as it appears and providing answers by selecting one or more answer choice;, as appropriate.
Follow rules associated with the questions. Rules display in brackets next to the question (for example, [ ≥ One, except Other clinical information (add comment)] is a rule).
If necessary, select to continue to the next question. Single answer questions automatically display the next question, while multi-answer questions display the Next button.
View any notes associated with the questions by selecting the note icon.
Optionally, view availability of the recommendations in the CriteriaView pane:
If closed, select CriteriaView to display the pane.
Select View All to see all recommendations or Selected to see only tracked recommendations. Tracked recommendations that become unavailable, based on your answers, are crossed off; for example, .
View the question that caused a recommendation to become unavailable by selecting the question mark next to the recommendation.

The Recommendation Availability dialog appears and shows the question. From here, you can view additional criteria and answer questions that lead to the recommendation or you can return to the medical review.

Note: If you choose not to view additional criteria at this point in the workflow, you can do so later in the Recommendations screen for any unavailable recommendations.

Continue with one of the following options:
View additional criteria and answer questions by continuing with step 5 below.
Return to the medical review and answer the remaining questions. Select the X to close the Recommendations Availability dialog, answer the remaining medical review questions, and then continue with step 6 below.
In the Recommendation Availability dialog, select VIEW ADDITIONAL CRITERIA.
Review the question that caused the recommendation to become unavailable, then using the rules that display in the highlighted box below each question as a guide, answer the questions.

Note: If you do not have all the required information, you may skip a question. Additionally, you are not required to answer the questions in any specific order; however, the rules may guide you to follow a certain path.
When you finish answering the questions, select ADDITIONAL CRITERIA COMPLETED or select the continue to recommendations link.

Note: selecting Cancel returns you to the medical review without saving your additional criteria responses.

The Recommendations screen appears. It shows why criteria for the recommendation were not met and, beginning with the question that caused the recommendation to become unavailable, lists each clinical scenario that would lead to the recommendation.
A check mark () indicates the answer you selected leads to the recommendation.
An X () indicates the answer you selected does not lead to the recommendation.
After you view the results, continue with any of the following options:
If appropriate, edit your selections for the same recommendation by selecting the edit icon next to the recommendation.
View additional criteria for another unavailable recommendation by selecting the Additional Criteria link and selecting a recommendation. Answering questions for a different recommendation will erase your current additional criteria responses. Select Yes or No in the warning message that appears.
Return to the medical review by selecting and answering the remaining questions. Answering the remaining questions will erase your additional criteria responses. Select Yes or No in the warning message that appears.
Select to use Decision Reasons for a review that did not meet criteria.
Select Review Summary and then continue with Viewing and Printing the Review Summary.
If you continued with the medical review, when you reach the end of the questions, select View Recommendations.

View recommendations and additional criteria

When a medical review is complete, the results display on the Recommendations screen.

The results vary depending on the product (for example, not recommended, one recommendation, more than one recommendation, mutually exclusive recommendations and so on). Additionally, if the CriteriaView feature is available, you may see recommendations that are no longer available.

View and select a recommendation

View the recommendation details:
Read any notes by selecting the note icon.
View the ICD, CPT^®,and HCPCS codes that apply to the recommendation by selecting Show Codes. Hide the codes by selecting Hide Codes.
View any values associated with the recommendation, such as hour(s) per day, time(s) per year, or visit(s). For example, a Home Physical Therapy recommendation might indicate a number visits within a given time frame, such as 6 visits within 2 weeks.
For Specialty Rx Oncology:
View the NCCN Drugs & Biologics Compendium (NCCN Compendium^®) rating for an off-label drug recommendation.
Optionally, view the NCCN Compendium^® rating description by moving the pointer over the rating number.
Optionally, access the National Comprehensive Cancer Network^® (NCCN^®) website by selecting the link within the red note.
For Level of Care: Home Care Q & A:
The results might show both Recommended Services and Not Recommended Services. This occurs when you select two or more services and at least one service is recommended and at least one service is not recommended.
Includes the number of visits and, if appropriate, the duration; for example, Physical Therapy – 6 Visits within 2 weeks.
Private Duty Nursing (PDN) Assessment recommendations include a suggested maximum number of private duty nursing hours per day and per week. Recommendations also have a total sum of points based on the selected answer choices. The sum of points falls within a predetermined range of points with the recommendation. The recommendation note provides information about the range of points.
Select a recommendation.

Selected recommendations change to green and automatically show the associated codes.
If benchmark information is available for an inpatient procedure, optionally, select a value:
Select Benchmarks.

The Utilization Benchmarks dialog appears.
If appropriate, find a procedure by entering a partial or complete description in the Indications box.
Select a procedure from the list.

The dialog closes and the selected value appears on the Recommendations screen.
Optionally, select codes:
Select the tab for the type of code you want to select.

Note: If you select ICD codes, you can select either ICD-9 or ICD-10 codes, but not both.
Search by medical code or description. Alternately, scroll through the list until you find the code you want.
Select a code. To clear a code, select it again.
If you select HCPC(S) codes for a Specialty Rx Oncology recommendation, you can enter a quantity amount for a drug on the HCPCS Code/NDC Crosswalk pane.
View the selected codes in the Selected tab. The value on the Selected tab reflects the number of codes you selected.
When you have finished selecting recommendations, do one of the following:
Optionally, view additional criteria for any unavailable recommendations.
Select and then continue with Viewing and Printing the Review Summary.

View additional criteria for recommendations that are no longer available

If the CriteriaView feature is available and a recommendation(s) is no longer available, you can view additional criteria and answer questions to see the clinical scenarios that lead to a recommendation.

Select the Why didn't a requested intervention meet criteria? link.

The Recommendation Availability dialog appears.
If more than one recommendation is available, select one from the list.
Review the question that caused the recommendation to become unavailable and then select VIEW ADDITIONAL CRITERIA.
Answer the questions using the rules that display below each question as a guide.

Note: If you do not have all the required information, you may skip a question. Additionally, you are not required to answer the questions in any specific order; however, the rules may guide you to follow a certain path.
When you finish answering the questions, select ADDITIONAL CRITERIA COMPLETED. (Selecting Cancel erases your additional criteria responses.)

The Recommendations screen results show why criteria for the recommendation were not met and, beginning with the question that caused the recommendation to become unavailable, lists each clinical scenario that would lead to the recommendation.
A check mark () indicates the answer you selected leads to the recommendation.
An X () indicates the answer you selected does not lead to the recommendation.
Optionally, continue with the following options:
If appropriate, edit your selections for the same recommendation by selecting the pencil icon next to the recommendation.
View additional criteria for another unavailable recommendation by selecting the Additional Criteria link and selecting a recommendation. Answering questions for a different recommendation will erase your current additional criteria responses. select Yes or No in the warning message that appears.
When you have finished, select , then continue with Viewing and Printing the Review Summary.

Note: Selections you make in the Additional Criteria workflow are saved with the review. This enables primary and secondary reviewers to view the Additional Criteria selections and resulting clinical scenarios in a saved review.