InterQual® Criteria

InterQual® Level of Care Criteria uses healthcare technology to provide healthcare organizations with the ability to prospectively, concurrently and retrospectively assess clinical appropriateness. Robust clinical detail allows organizations to evaluate severity of illness, comorbidities and complications, as well as the intensity of services being delivered, to determine the most suitable and safest level of care. The criteria also assist in discharge planning and care transitioning across the continuum. Medicare policy notes and a direct link to the Medicare Benefit Policy Manual provide additional information within the medical review workflow to support policy alignment.

Assess

Assess the safest and most efficient level of care for more than 95% of reasons for admission.

Evaluate

The criteria provide care management information notes for expected progress, care facilitation and readmission considerations. Criteria also include length-of-stay benchmarks and transition planning tools.

Manage

The criteria incorporate management of comorbid conditions upon admission, along with continued stay.

Included modules

InterQual Acute Adult Criteria

The InterQual® Acute Adult module helps clinicians evaluate the appropriateness of admission, continued stay and discharge of acute care patients aged 18 and older. Criteria are organized by primary condition presented in a single view that incorporates relevant complications, comorbidities, guideline standard treatments, proactive care management guidance and length-of-stay benchmarks. By addressing the complete needs of each patient, the criteria facilitate movement of patients through the care continuum based on their conditions and responses to treatment. This integrated, holistic approach provides a powerful mechanism for decreasing inappropriate admissions, avoidable days and readmissions.
InterQual Acute Pediatric Criteria

The InterQual® Acute Pediatric module helps clinicians determine the appropriateness of admission, continued stay and discharge at acute care facilities for patients under 18 years of age. The module features the same condition-specific format as the adult criteria.
InterQual Long-Term Acute Care Criteria

The InterQual® Long-Term Acute Care module helps clinicians determine the appropriateness of admission, continued stay and discharge for long-term acute care patients. This module includes responder and partial-responder criteria to help clinicians adjust patient care time frames and interventions based on outcomes. It also offers guidance around discharge and transition planning for patients who no longer require skilled care or whose care can be safely managed in an outpatient setting or at a lower level of care.
InterQual Inpatient Rehabilitation Criteria

The InterQual® Inpatient Rehabilitation module helps clinicians determine appropriateness of admission, continued stay and discharge at inpatient rehabilitation facilities for adult and pediatric populations. The module includes methods for addressing complications and setbacks associated with the onset of medical instability in a timely and medically appropriate way.
InterQual Subacute and Skilled Nursing Criteria

The InterQual® Subacute and Skilled Nursing module helps clinicians identify medical necessity and the most suitable level and complexity of care based on clinical need and stability. Guidance is provided for discharge and transition planning. Clinical evidence supports the appropriateness of skilled treatments and services to ensure optimal care and to help organizations withstand audit scrutiny.
InterQual Home Care Criteria

The InterQual® Home Care module streamlines care management for patients who require services in the home setting. The criteria help determine the appropriateness of the initial review and ongoing service needs, visit recommendations and discharge. The criteria address both adult and pediatric patients and include intermittent skilled home care services, private duty nursing, hospice and palliative care needs.
InterQual Rehabilitation and Chiropractic Criteria

The InterQual® Outpatient Rehabilitation and Chiropractic module illuminates the most suitable level and complexity of rehabilitation and chiropractic care in addition to maintenance therapy and habilitation. The criteria help clinicians screen for initial authorization and ongoing care needs. Guidance around discharge and transition planning to help avoid costly readmissions is also provided. Coordination in the outpatient rehab and chiropractic setting can help improve outcomes, minimize costs and ensure timely transitions to appropriate levels of care.