Evaluating Criteria in a Medical Review

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

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

To evaluate criteria in a medical review:

Following are optional, review-related tasks you might perform as you evaluate criteria:

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

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.

  • Click Comments buttonto add a comment to the review or click the appropriate comments icon Comments icon for a criteria point.

    The Reviewer Comments dialog box appears.

  • Enter your comment in the text box.
  • Click Add Comment.

  • Click the X to close the dialog box.

    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 clicking Comments. If you added a comment to a criteria point, click 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.

  • Click Commentsto open the Reviewer Comments dialog box.
  • To edit a comment, click the edit icon Edit icon for the appropriate comment and then type the changes in the text box. Click Done to save your changes.
  • To delete a comment, click the delete icon Delete icon for the appropriate comment and then click DELETE in the confirmation message.
  • Click the X to close the dialog box.

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 claims data from Change Healthcare, one of the industry’s largest claims clearinghouses, representing millions of patient encounters. InterQual benchmarks create guidance designed to facilitate efficient management of the patient to that target. Benchmarks are not intended to serve as treatment limits or substitute for clinical judgement.

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

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.

Select a benchmark as follows:

  • Click BENCHMARKS.

    The Utilization Benchmarks dialog box 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.

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

To view care management information:

  • If closed, click CARE MANAGEMENT to slide out the pane, or click the arrow Criteria Management icon 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, click 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; BH: Adult and Geriatric Psychiatry, BH: Child and Adolescent Psychiatry, BH: Substance Use Disorders; CP: Retrospective Monitoring and Specialty Referral products.

  • Select a subset and then click Begin Medical Review
  • Depending on the subset you selected, do the following:
  • Acute Adult and Pediatric—Select an Episode Day (or Initial Review) from the list.
  • Long Term Acute Care and Inpatient Rehabilitation—Select a review type (that is, Preadmission, Admission, Continued Stay, or Discharge).
  • 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.
  • CP: Specialty Referral and CP: Retrospective Monitoring—Select an indication from the list.
  • Expand the decision tree as follows:
  • Click a plus sign Plus sign icon to expand a section of the decision tree and click a minus sign Minus sign icon to collapse it.
  • Click Expand All to expand all criteria in the decision tree and click Collapse All to collapse it.
  • View any notes associated with the criteria by clicking the appropriate note icon:
  • Informational Note Note icon—Provides reminders of best medical practice, new clinical knowledge, procedural information, explanations of criteria rationale, and current literature references.
  • Quality Indicator Note Quality Indicator note icon—Indicates that quality indicator data exists for this condition.
  • Transition Plan Note Transition Plan note icon—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.
  • Note (Red) Mandatory note icon—Associated with an indication or criteria point, these mandatory notes provide important information that you must read while conducting a review.

  • Care Management Note Care Management note icon—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 Two midnight rule icon—Provides instructions for the Two-Midnight rule.
  • Select criteria points:
  • Click a criteria point to select it. Selected criteria change to green and have a check mark Check mark. To revert the criteria back to unselected, select it again.
  • To explicitly indicate that a criteria point does not satisfy criteria, select the X on the criteria point . The criteria point changes to red and appears with an X . To revert the criteria back to unselected, select the X again.
  • 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 Criteria point showing abbreviation example.
  • If you select a criteria point that redirects you to a more appropriate subset that has multiple versions enabled, you will be 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 clicking Previous or clicking Menu and selecting an option from the navigation pane. You can return to the medical review by clicking Resume Medical Review.

  • If you select a criteria point that automatically displays a note (for example, a transition plan), read the note and then click 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, click for a review that did not meet criteria, or go to the Review Summary by clicking Medical Review Completed .
  • Continue with Using Decision Reasons, or Viewing and Printing the Review Summary.

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

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

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 About 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

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

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

Add reviewer comments

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

  • Click Comments button to add a comment to the review or click the appropriate comments icon Comments icon for a question.

    The Reviewer Comments dialog box appears.

  • Type your comment in the text box.
  • Click Add Comment.

  • Click the X to close the dialog box.

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

  • You can view the details of added comments by clicking Comments.

Edit or delete reviewer comments

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

  • Click Comments buttonto open the Reviewer Comments dialog box.
  • To edit a comment—Click the edit icon Edit icon for the appropriate comment and then type the changes in the text box. Click Done to save your changes.
  • To delete a comment—Click the delete icon Delete icon for the appropriate comment and then click DELETE in the confirmation message.
  • Click the X to close the dialog box.

  • 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, click Next button 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 clicking the noteNote icon icon.
  • Required questions appear with the word Required in red text next to a question.
  • When you reach the end of the questions, click View Recommendations.

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

  • View the recommendation details:
  • Read any notes by clicking the note icon.
  • View the ICD, CPT®,and HCPCS codes that apply by clicking Show Codes. Hide the codes by clicking 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 clicking 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 by clicking it.

    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:

  • Click Benchmarks.

    The Utilization Benchmarks dialog box 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 box closes and the selected value appears in the Recommendations screen.

  • Optionally, select codes:

  • Click 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.
  • Click a code description to select it. Click again if you want to clear a code.

  • View the selected codes by clicking Selected . The value on the Selected button reflects the number of codes you selected.

  • When you have finished selecting recommendations, continue as follows:
  • If appropriate, click to use Decision Reasons for a review that did not meet criteria.
  • Click Review Summary and then continue with Viewing and Printing the Review Summary.

There are two steps to evaluating criteria in a medical review

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

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

As you evaluate criteria, you can add comments to the review or to specific medical review questions.

Add reviewer comments

  • Click Comments buttonto add a comment to the review or click the comments icon Comments icon for a question.

    The Reviewer Comments dialog box appears.

  • Type your comment in the text box.
  • Click Add Comment.

  • Click the X to close the dialog box.

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

  • You can view the details of added comments by clicking Comments.

Edit or delete reviewer comments

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

  • Click Commentsto open the Reviewer Comments dialog box.
  • To edit a comment—Click the edit icon Edit icon for the appropriate comment and then type the changes in the text box. Click Done to save your changes.
  • To delete a comment—Click the delete icon Delete icon for the appropriate comment and then click DELETE in the confirmation message.
  • Click the X to close the dialog box.

ⓘ  Note: If the CriteriaView feature is not available, skip steps 2, 4, and 5 in the directions below.

  • Select a subset and then click Begin Medical Review
  • Optionally, select recommendations you want to track:

  • Click CriteriaView on the right side of the screen to display the CriteriaView pane. Hide the pane at any time by clicking CriteriaView again or, optionally, leave it open as you answer the questions.

    The CriteriaView pane displays a list of recommendations for the subset.

  • Click Select All 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, click Next button 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 clicking the note Note icon icon.
  • Optionally, view availability of the recommendations in the CriteriaView pane:
  • If closed, click CriteriaView to display the pane.

  • Click View All to see all recommendations or click Selected to see only tracked recommendations. Tracked recommendations that become unavailable, based on your answers, are crossed off; for example, Image of crossed off recommendation.

  • View the question that caused a recommendation to become unavailable by clicking the question mark (Question mark icon) next to the recommendation.

    The Recommendation Availability dialog box 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. Click the X to close the Recommendations Availability dialog box, answer the remaining medical review questions, and then continue with step 6 below.
  • In the Recommendation Availability dialog box, click 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, click ADDITIONAL CRITERIA COMPLETED or click the continue to recommendations link.

    ⓘ  Note: Clicking 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 checkmark (Checkmark icon) indicates the answer you selected leads to the recommendation.
  • An X (X icon) 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 clicking the edit icon next to the recommendation Image showing recommendation.
  • View additional criteria for another unavailable recommendation by clicking the Additional Criteria link and selecting a recommendation. Answering questions for a different recommendation will erase your current additional criteria responses. Click Yes or No in the warning message that appears.
  • Return to the medical review by clicking Previous button and answer the remaining questions. Answering the remaining questions will erase your additional criteria responses. Click Yes or No in the warning message that appears.
  • Click to use Decision Reasons for a review that did not meet criteria.
  • Click 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, click View Recommendations.

When a medical review is complete, the results display in 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.

Image of Recommendations screen

View and select a recommendation

  • View the recommendation details:
  • Read any notes by clicking the note icon.
  • View the ICD, CPT®,and HCPCS codes that apply by clicking Show Codes. Hide the codes by clicking 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 clicking 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.

  • Select a recommendation by clicking it.

    Selected recommendations change to green and automatically display the associated codes.

  • If benchmark information is available for an inpatient procedure, optionally, select a value:

  • Click Benchmarks.

    The Utilization Benchmarks dialog box 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 box closes and the selected value appears in the Recommendations screen.

  • Optionally, select codes:

  • Click 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.
  • Click a code description to select it. Click again if you want to clear a code.
  • 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 by clicking Selected. The value on the Selected button 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.
  • Click Review Summary and then continue with Viewing and Printing the Review Summary.

View additional criteria for recommendations 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.

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

    The Recommendation Availability dialog box 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 click 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, click ADDITIONAL CRITERIA COMPLETED.

    ⓘ  Note: Clicking 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 checkmark (checkmark icon) indicates the answer you selected leads to the recommendation.
  • An X (x icon) 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 clicking the pencil icon next to the recommendation image of recommendation.
  • View additional criteria for another unavailable recommendation by clicking the Additional Criteria link and selecting a recommendation. Answering questions for a different recommendation will erase your current additional criteria responses. Click Yes or No in the warning message that appears.

  • When you have finished, click Review Summary, 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.