June 18, 2020
LifeWise is expanding the use of InterQual criteria to review many services effective July 2, 2020.
InterQual evidence-based clinical criteria are used to determine the safest and most appropriate medical services for our members. The criteria consider severity of illness, additional medical conditions, and the location where medical care is provided.
To align with consistent, industry standard decision-making tools, a utilization review nurse or clinician will use InterQual criteria to determine if the medical services are appropriate. When criteria are met, the case is approved. If the criteria aren’t met, the case is referred to a LifeWise medical director. Only physicians can determine lack of clinical appropriateness.
Refer to the following table to see the services InterQual criteria currently applies to and the coming additions.
| InterQual Criteria | Current | Effective July 2, 2020 |
| Impatient Criteria | ||
|---|---|---|
| Acute adult |  | |
| Acute pediatric | | |
| Acute rehabilitation | | |
| Long-term acute care (LTAC) | | |
| Behavioral Health Criteria | ||
| Adult and geriatric psychiatry | | |
| Child and adolescent psychiatry | | |
| Substance use disorders | | |
| Care Planning | ||
| Durable medical equipment (DME) - select | | |
| Procedures - select | |
InterQual updated policies are available in the Medical Policy and Coding Updates.
To view InterQual criteria, sign in to our provider website. We’ll provide more information in future communications.
For questions about LifeWise’s policies, send us an email.