InterQual® Criteria Features

InterQual® Criteria are the clinical information the reviewer should consider when conducting reviews. Criteria comprise evidence-based clinical statements and rules for their application.

Depending on the product you select, criteria are organized in one of two formats:

Decision Tree

Question and Answer (Q&A)

Decision Tree

ⓘ  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; and CP: Retrospective Monitoring and Specialty Referral products.

In this format, the criteria are presented in a decision tree workflow in which you can see all the clinical statements and rules as you select criteria to conduct a review. Criteria includes indications, criteria points, rules, and notes. You can select as many criteria points as you like or as recommended by your organization. However, only the minimum must be selected (as required by the rules) in order for criteria to be met.

Criteria in decision-tree format have these features:

  • Criteria points: Refer to test results, medications, symptoms findings, or medical management. Criteria points support the reasons or indications; that is, they identify specific clinical elements that must be satisfied to justify the appropriateness of the intervention/service.
  • Criteria in a decision tree have top-level criteria points with one or more levels of underlying criteria points.
  • Rules: Specify how many of the underlying criteria points are needed to meet criteria, ensuring that reviewers apply criteria consistently. One, Both, and All are examples of rules.
  • In Level of Care Acute Criteria and Care Planning (Specialty Referral) Criteria, in some cases, to meet criteria, the patient must meet criteria for a criteria point with a rule AND for the underlying criteria. If you select criteria with this rule and you don't complete the selection, an indicator and text will appear to prompt you to finish the selection.
  • Simple All: In Level of Care and Behavioral Health Criteria, where clinically appropriate, if you select a parent criteria point with a rule of All (or Both) that has only one level of underlying criteria points, then all of those underlying criteria points are automatically selected.
  • Rule of One: For this rule, you can select only one underlying criteria point. If you select a second criteria point, an error message appears.
  • Criteria Status: The criteria status (initially, Criteria Not Met) displays as you conduct a review. If you select criteria points that meet the criteria, the status changes to Criteria Met. In Level of Care, Acute Adult or Pediatric criteria subsets, if you select criteria points that meet criteria for a specific level of care, the status indicates that level of care ( for example, Acute Met). For more information on criteria status, see About Criteria Status.
  • Criteria Notes: Provide information such as explanations, definitions of medical terminology, information about a clinical condition, and specific reviewer instructions. For more information on criteria notes, see Notes and Symbols.

Question and Answer (Q & A)

ⓘ  Note: Applies to InterQual® LOC: Home Care Q & A and Outpatient Rehabilitation & Chiropractic; InterQual® BH: Behavioral Health Services; 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®1 Navigator.

In this format, criteria are presented in an interactive question-and-answer workflow that represents the same types of clinical statements and rules as those presented in a decision tree. As you conduct a medical review, your answers will lead you to the most appropriate drug, procedure, imaging study, test, service, or medical equipment. When you complete the medical review, the results display in the Recommendations screen where you can choose among the recommendations, if any.

Questions and Recommendations

Answers are in one of the following formats:

  • Single-response: Choose one.
  • Multiple select: Choose all that apply.

The questions may also include criteria notes and rules that provide additional information and directions.

Each recommendation might have the following associated with it.

  • Medical codes such as ICD, CPT®, and HCPCS.
  • Rules that specify how some recommended services should be used with each other or should be mutually exclusive. For example, a Mutually Exclusive (ME) rule indicates that you can select only one of the recommendations.
  • Utilization benchmark information, which provides guidance around a typical length of stay for a condition, is available for inpatient procedures in the Care Planning: Procedures.
  • A value 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 of visits within a given time frame, such as 6 visits within 2 weeks.
  • Flags that provide explanatory text based on the results from the medical review. For example, a recommendation for a prescription medication might have an off-label flag. Specialty Rx Oncology drugs that are recommended for off-label use are based on the NCCN Drugs & Biologics Compendium (NCCN Compendium®.