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 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.
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