July 2024
We’ll use 2024 InterQual criteria, starting Aug. 1
On Aug. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2024 InterQual® criteria to make determinations on prior authorization requests for the medical – non-behavioral health – services we manage for these members:
- Blue Cross commercial
- Medicare Plus Blue℠
- BCN commercial
- BCN Advantage℠
If InterQual criteria are updated to correct known issues or errors, we’ll use the updated criteria as soon as they’re available.
Blue Cross and BCN also use local rules for prior authorization requests for post-acute care that include inpatient rehabilitation, skilled nursing facility and long-term acute care. These local rules are modifications of InterQual criteria that we use in making determinations. You can access the local rules on the Services that need prior authorization page on bcbsm.com. We’ve updated that page to include the most current version of the local rules.
Refer to the table below for more specific information about which criteria we use in making determinations for various types of non-behavioral health prior authorization requests.
Criteria |
Services |
InterQual acute — Adult and pediatrics |
- Inpatient admissions
- Continued stay discharge readiness
|
InterQual level of care — Sub-acute and skilled nursing facility |
- Sub-acute and skilled nursing facility admissions
- Continued stay discharge readiness
|
InterQual rehabilitation — Adult and pediatrics |
- Inpatient admissions
- Continued stay and discharge readiness
|
InterQual level of care — Long-term acute care |
- Long-term acute care facility admissions
- Continued stay discharge readiness
|
InterQual imaging |
- Imaging studies and X-rays
|
InterQual procedures — Adult and pediatrics |
- Surgery and invasive procedures
|
Medicare coverage guidelines (as applicable) |
- Services that require clinical review for medical necessity and benefit determinations
|
Blue Cross and BCN medical policies |
- Services that require clinical review for medical necessity
|
Local rules for post-acute care (applies to inpatient rehabilitation, skilled nursing facility and long-term acute care admissions for Blue Cross commercial and BCN commercial) |
- Exceptions to the application of InterQual criteria that reflect the accepted practice standards for Blue Cross and BCN
|
When clinical information is requested for a medical or surgical admission or for other services, we require health care providers to submit specific components of the medical record that show that the request meets the criteria. We review this information when making determinations on prior authorization requests.
Note: The information in this article applies to members whose authorizations are managed by Blue Cross or BCN directly and not by independent companies that provide services to Blue Cross or BCN. |