InterQual® Ambulatory Care Planning Criteria

The InterQual® Procedures module covers more than 500 high-volume, high-cost procedures and includes all major organ system categories for both adults and children. Using a proprietary setting benchmark, the criteria recommend whether the procedure or surgery should be performed in an inpatient or outpatient setting. They also indicate whether appropriate, less-invasive interventions have been attempted prior to a surgical or more invasive procedure. Length-of-stay data is provided as benchmarks for select procedures. 

The InterQual® Imaging module covers over 200 unique imaging tests organized into more than 30 test families, including a full spectrum of high-volume, high-cost tests. Cases in which the evidence does not fully support a specific test and may require a secondary review are identified. Cases when alternative studies are appropriate based on medical evidence and the specific clinical scenario are also identified.  

The InterQual® Durable Medical Equipment module supports the medical necessity documentation required for authorization of more than 450 pieces of equipment and accessories. The criteria address commercial adult and pediatric populations. Equipment is presented in a hierarchy of cost and complexity, and guidance is provided within a single review workflow for accessories often included with high-volume equipment.  

The InterQual® Molecular Diagnostics module provides criteria that cover over 800 molecular and genetic diagnostic tests organized into more than 130 test families. Newly developed and complex diagnostic tests and test panels are also presented. The criteria include guidance for lower cost, nonmolecular tests that may be clinically appropriate. Clinical evidence summaries provide extensive support.

The InterQual® Specialty Rx Oncology module helps guide the appropriate use of oncology drugs for both on- and off-label indications. The criteria include evidence-supported regimens that indicate when it is appropriate to give a drug in combination with one or more additional medications. The Specialty Rx Oncology module is an automated source for National Comprehensive Cancer Network® recommendations on appropriate use of off-label prescription drugs and biologics in patients with cancer.  

The InterQual® Specialty Rx Non-Oncology module helps guide the appropriate use of non-oncology drugs, providing clear guidance on step therapy and addressing both on- and off-label indications. The criteria cover more than 140 drugs for many common conditions.

The InterQual® Specialty Referral module provides information on which type of specialist should be consulted. It includes objective clinical criteria for interventions that should be completed prior to specialist engagement. Guidance is available for typical duration and sequencing of involvement for more than 160 conditions or disorders.

The InterQual® Retrospective Monitoring module supports retrospective assessments of more than 260 surgical and nonsurgical invasive procedures to identify opportunities for care delivery improvement. Robust reporting helps determine if procedures were medically appropriate and correct interventions were conducted prior to the surgery or procedure. When problems are identified, the module helps organizations determine if the issue was an isolated event or part of a larger pattern.