Cranial nerve stimulator including vagus nerve and hypoglossal nerve interqual care planning, specialized procedures, vagus nerve stimulation. Click a topic to view sources for the medical necessity criteria that ucare uses in utilization management decisions. Interqual application and training tenet healthcare. When criteria for admission are not met or not enough information is available to complete the questionnaire, the. Medical criteria generally interqual criteria is used to determine medical necessity and is found in the online authorization tool. Interqual criteria in order to maintain consistency made up of 30 developers, 650 external consultants, 110 experts in mental health bcbsma uses mckesson corporations interqual criteria in order to maintain consistency made up of 30 developers, 650 na both developed externally using interqual criteria. Interqual criteria connects and aligns payers, providers and other organizations with actionable, evidence. Interqual care criteria guidelines learn how to have the answers for that interqual care criteria guidelines.
Admission criteria for care management admission criteria. A copy of the criteria used are available to providers via fax or mail based upon request. Scott and white health plan notificationprior authorization list. Follow prompts to download the file to your computer. When interqual admission criteria are met for the level of care requested, the request will be approved immediately, and no further action will be required. Application of interqual criteria care managers use interqual evidencedbased decision support software to assist with validating the appropriate level of acute care including admission as an inpatient or observation patient, continued stay and discharge. Interqual criteria are objective and specific to better help ensure the most appropriate care and more consistent, defensible decisionmaking. Patient financial services weekly advisor, june 21, 2007. Sources of utilization management criteria for gehas. On november 23, 2019, blue cross and blue shield of minnesota and blue plus blue cross added a new feature to the authorization process for hospital, inpatient rehabilitation and longterm acute care ltac admission submitted on.
Supporting accurate and current coding practices and provider reimbursement is part of that commitment. Therefore, not fulfilling the criteria does not ensure survival. Medical coverage policy update notice medical coverage. Generally interqual criteria is used to determine medical necessity and is found in the online authorization tool. Revenue hpes interqual payment per day loc description. Beacon will work with your plan and the office of mental health to address any concerns impacting approval of the criteria, for the march 1 transition. Jan 17, 2017 mckesson brings interqual criteria to the cloud. Interqual acute adult criteria help determine the appropriateness of admission, continued stay and discharge at acute care. The medical policies and clinical um guidelines are determined by wellpoints. Interqual criteria manual interqual criteria 2018 7.
If the clinical criteria source is bcbsri and a separate policy title is not listed, use the medical criteria found in this genetic testing services policy. Cms coverage database interqual criteria available upon request. Interqual criteria and aetna clinical policy bulletins to support benefit determinations related to medical necessity and. Once on the dlc home page, scroll down to browse my software and documentation and click on interqual 4. If interqual criteria is not available, selecthealth medical necessity policy. The criteria for the four levels of neonatal care are laid out in the neonatal admission levels comparison chart in mcg. If interqual criteria is not available, selecthealth medical necessity policy will be applied. Department of health care services public hospital.
A column will open on the right with a list of interqual product lines, select interqual view. A new approach to inpatient admission status part 1 of 2. Clinical criteria for um decisions long term acute care hospitalization capital health plan provides coverage for long term acute care ltac hospitalization for intensive management of complex medical needs, when the members needs cannot be safely met in a less restrictive setting, such as a skilled nursing facility or an inpatient. When no interqual criteria exists, ucare utilizes the guidelines established by medicare through national and. Each criteria product can work independently or with other criteria sets. Rearrange individual pages or entire files in the desired order.
To request a copy of the clinical criteria, please call tollfree phone number is 18663343141 medicare lines of business or 18003217947 all other lines of business. Mckesson brings interqual criteria to the cloud business. These criteria need to be subjected to a prospective, multicentre clinical trial to establish their utility and determine whether there. However, for those policies specifically listed in the related policies section of this policy, bcbsri. Each tenet hospitals director of case management dcm is responsible for establishing competency in the application of interqual, the implementation of the interqual education plan as established by the. If the clinical criteria source is bcbsri and a separate. Utilization management vanderbilt university medical center. Customizations to mckesson interqual criteria issue date.
Chapter 8 medical management and quality management. Qp10119 interqual level of care criteria for concurrent. Milliman, nih, interqual, proprietary guidelines available upon request for a specific case. Mckesson interqual criteria from now on referred to as customized criteria. However, for those policies specifically listed in the related policies section of this policy, bcbsri medical criteria is used. Need to discuss using interqual criteria for medical benefit versus creating homegrown criteria to match pharms. A partial hospitalization program php is a time limited, ambulatory treatment program offered during the day or evening hours, and is considered an acute day hospital or a level 2. Mckesson brings interqual criteria to the cloud business wire. Policy partial hospitalization program php accreditation guidelines. Please note that the these are suggestions based on interqual criteria and milliman criteria used by medicare, tenncare tenncare and most of the major payers.
When utah medicaid does not have a coverage policy, interqual criteria will be used. The wellpoint policy process and a description of it are available on the unicare website. Jun 21, 2007 are hospitals bound by interqual criteria when determining patient status. Clinically appropriate consistent throughout vuh provided in the most appropriate care setting based on current clinical best practices, data, and medical literature. Sm registered and service marks of the blue cross and blue shield association. This is the same definition as specified in nac 442. On november 23, 2019, blue cross and blue shield of minnesota and blue plus blue cross added a new feature to the authorization process for hospital, inpatient rehabilitation and longterm acute care ltac admission submitted on the availity portal. We have got this document available for immediate free pdf download. The infection criteria were updated to help improve workflow and consistency and new criteria was added for dengue fever, typhoid and ebola. I have a question about what to do when a physician writes orders to admit a patient to the hospital as an inpatient, but the patient did not meet interqual criteria for inpatient status.
Physicians, not the hospital or case managers, are responsible for making the correct determination. Emergency liver transplantation for acute liver failure. Cpthcpcs code brand name, if known coverage preauthorization method clincal criteria source coverage preauthorization method clincal criteria source comments andor related policy 81105. Medicare clinical criteria for um decisions long term acute. Pap905 partial hospitalization program php accreditation. This level reflectslow birth weigth neonates who are not sick but require frequent feeding and neonates who require more hours of nursing than do normal neonates, considered to be continuing care. Case management means a collaborative process of assessment, planning. Department of health care services public hospital project. These criteria need to be subjected to a prospective, multicentre clinical trial to establish their utility and determine whether there is a need for further refinement. Qualis health wyoming medicaid dme educational session. Key search terms included milliman guidelines, milliman care. Interqual actionable evidencebased criteria portfolio.
A summary document of the environmental scan was created and is available on the ptac. Blue cross blue shield of massachusetts is an independent licensee of the blue cross and blue shield association. Utilization management criteria ucares utilization management program is based on nationally recognized, evidencebased medical necessity guidelines as developed by national vendor, change healthcare. Change to clinical utilization management guidelines. Our four criteria suites provide comprehensive coverage for medical and behavioral health across all levels of care as well as ambulatory care planning.
Medical procedures are considered medically necessary when the criteria in the bcbsri online prior authorization tool has. Interqual is evidencebased criteria that offers guidance in covering medical and behavioral health for all levels of care in addition to care planning and complex care management. Are hospitals bound by interqual criteria when determining patient status. Change to clinical utilization management guidelines why is this change necessary.
A new approach to inpatient admission status acp hospitalist. Ucare uses the decision support tool, interqual, which is provided electronically by change healthcare. Qualis health wyoming medicaid dme educational session yvette stratton, rn, bsn, ccm manager, care management department. Lack of preauthorization if a contracted or noncontracted provider submits a claim for a service that requires preauthorization but has not been preauthorized, the service will be denied and if additional records are submitted, will undergo. Interqual is evidencebased criteria that offers guidance in covering medical and behavioral health for all levels of care in addition to care planning, complex care management, durable medical equipment, and procedures. Although fulfillment of these criteria has a high specificity for mortality, the sensitivity and negative predictive value remain low. Customers now have ondemand access to interqual as a software service. Wellpoint recently acquired amerigroup and all of its subsidiaries. Get interqual criteria manual pdf file for free from our online library created date. Qp10518 interqual level of care criteria for authorizations. Interqual acute pediatric criteria updates include nursery and bronchiolitis enhancements.
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