InterQual Criteria Used to Review Services

  • June 18, 2020

    Premera 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 Premera 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
    Inpatient Criteria    
    Acute adult check  
    Acute pediatric check  
    Acute rehabilitation check  
    Long-term acute care (LTAC) check  
    Behavioral Health Criteria    
    Adult and geriatric psychiatry check  
    Child and adolescent psychiatry check  
    Substance use disorders check  
    Care Planning    
    Durable medical equipment (DME) - select   check
    Procedures - select   check

    InterQual updated policies are available in the Medical Policy and Coding Updates.

    Always refer to the code check tool, prior authorization tool, or code list for prior authorization and medical necessity review requirements.

    To view InterQual criteria, sign in to our provider website. We’ll provide more information in future communications.

    For questions about Premera’s policies, send us an email.

  •    Email this article