Viewing Critieria 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.

View decision tree criteria

View Q&A criteria

View decision tree criteria

  • Select Print and then depending on the options available, select one of the following:

  • Current selection - creates a printable version of the criteria you are currently viewing.
  • Full subset - creates a printable version of the entire subset.

  • Depending on the options available, select Open or select Download PDF.

  • Use the controls in the PDF to save and/or print the PDF.

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 decision-tree 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 (inpatient only), and Substance Use Disorders (Inpatient and Inpatient Detoxification)

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.

View 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.

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 Care Management 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.
  • Select a subset and then select View Criteria.
  • 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 from the list.
  • Expand the decision tree as follows:
  • Select a plus sign Plus sign icon to expand a section of the decision tree and select a minus sign Minus sign icon to collapse it.
  • Select Expand All to expand all criteria in the decision tree and select Collapse All to collapse it.
  • For criteria points that include abbreviations, symbols, or terms with a dotted underline, move the pointer over the underlined item to display the definition of the abbreviation or symbol, or full description of the term. For example, the abbreviation NIPPV is underlined in this criteria point .
  • Use the vertical scroll bar to see all the criteria.
  • View any notes associated with the criteria by selecting the appropriate note icon:
  • Informational note Informational note — provides reminders of best medical practice, new clinical knowledge, procedural information, explanations of criteria rationale, and current literature references.
  • Transition Plan note 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 Red 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 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 Two midnight rule note — provides instructions for the Two-Midnight rule.
  • When you finish viewing criteria, do any of the following:
  • Select Change Subset from the side menu
  • Select Previous to return to the Subset Select screen
  • Open the side menu and select Sign Out to close the application..

View Q&A criteria

Viewing criteria includes answering questions and viewing recommendations:

Answer questions

  • Select a subset and then select View Criteria.
  • Answer the questions by reviewing each one as it appears and selecting one or more answers, as appropriate.
  • Follow any 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.
  • When you reach the end of the questions, select View Recommendations.

View recommendations

When you complete the questions, 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).

  • View the details of any recommendations as follows:
  • Read any notes by selecting the note icon.
  • View the ICD, CPT®,and HCPCS codes that apply by selecting Show Codes, and then selecting the appropriate tab. 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.
  • If benchmark information is available for an inpatient procedure, optionally, view the values:

  • Select Benchmarks.

    The Utilization Benchmarks dialog box appears.

  • If appropriate, find a procedure by entering a partial or complete description in the Indications box.
  • Select the Close button (X) when you have finished viewing the results.
  • When you finish viewing criteria, you can select a different subset or exit the application:
  • Select CHANGE SUBSET from the menu
  • Select PREVIOUS until you return to the Select Subset screen
  • Open the side menu and select Sign Out to close the application.