InterQual® Solution. An evidence-based clinical decision support solution for payers, providers, and government agencies who want to help ensure clinically appropriate medical-utilization decisions.
What specifies how many of the underlying criteria points are needed to meet criteria ensuring that reviewers apply criteria consistently?
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.
Is InterQual evidence-based?
InterQual® Criteria are produced using a rigorous development process based on the principles of evidence-based medicine (EBM) to give you complete confidence in the underlying guidance the criteria provide.
Which resource provides details of changes to InterQual clinical criteria?
InterQual Clinical Reference is accessible from the Help menu within IQ View and Review Manager.
Who owns InterQual criteria?
While UHC framed its decision as a response to provider requests, it coincides with the recent purchase of Change Healthcare, which maintains the InterQual Criteria, by Optum, the healthcare analytics company owned by UHC’s parent company, UnitedHealth Group.
What is InterQual level of care criteria?
Clinical decision support for providers and payers who want to assess safe and efficient level of care based on illness severity, comorbidities, and complications.
Who developed InterQual?
Jacobs created InterQual in 1976. InterQual analyzes the resources that hospitals use to treat patients with the same diagnosis and helps predict future patients’ length of stay and cost of care. In the mid-1980s he cocreated MediQual, a similar but more complicated program used to analyze doctor performance.
What is the InterQual transition plan tool?
InterQual’s Acute Care module also includes: Transition Plans to help foster the movement of patients safely through the continuum of care and reduce readmissions; InterQual Benchmark and CMS Geometric Mean Length of Stay data available as targets to assist discharge planning; and Proactive Care Management Guidance
Does Medicare use InterQual criteria?
McKesson Health Solutions announced today that the Centers for Medicare & Medicaid Services (CMS) will continue their long-term use of InterQual® Criteria for Medicare services auditing programs.
What is the purpose of utilization review?
Utilization review is a method used to match the patient’s clinical picture and care interventions to evidence-based criteria such as MCG care guidelines. This criteria helps to guide the utilization review nurse in determining the appropriate care setting for all levels of services across the arc of patient care.
What does InterQual Connect do?
InterQual® Connect
An integrated medical review and connectivity solution for payers and providers who want to automate prior authorizations within their existing workflows.
What is MCG and InterQual?
The two predominant sets of criteria, MCG and InterQual, differ in many ways but they have one thing in common: They are both clinical screening criteria that are used to recommend the medical necessity and proper setting for care – in this case whether outpatient with observation or inpatient status is appropriate.
What are InterQual SmartSheets?
InterQual® SmartSheets provide a concise format of InterQual Criteria that helps facilitate communication between payers and providers.
What is the difference between Milliman and InterQual?
InterQual’s criteria are, in some respects, stricter than Milliman’s, with more precise clinical benchmarks for each level of care. That could mean an uptick in denials for cases in which the patient is borderline for inpatient vs. observation or discharge vs. continued stay.
Did UHC buy InterQual?
We will transition to InterQual criteria for all benefit plans effective May 1, 2021. We expect that using InterQual will further streamline our current clinical review processes while helping to reduce clinical decision turnaround times.
Does Medicare use InterQual or Milliman?
In addition to hospital use, many payers, third party consultants and Medicare quality contractors use McKesson Interqual criteria. Others use Milliman or other systems. Technically, Medicare does not specify or require Interqual or any other medical necessity screening criteria.
How do I become a utilization review nurse?
The minimum credentials for working in utilization review are being licensed as a registered nurse and having a good base of general nursing experience in medical-surgical nursing. Many employers require a BSN over an associate’s degree, and sometimes specific certifications in utilization review or risk management.
