Criteria are also available upon request by calling 8004425305. Magellan uses mcg care guidelines, along with its proprietary clinical. Utilization management case management study guide. Interqual level of care criteria 2010, acute care, adult on. Thanks to the wide availability of the internet all over the world, it is now possible to instantly share any. Our four criteria suites provide comprehensive coverage for medical and behavioral health across all levels of care as well as ambulatory care planning. Download the june 2015 edition independence blue cross.
Robertson andor interqual and some internally developed 2015 service authorization report. Interqual criteria connects and aligns payers, providers and other organizations with actionable, evidence. Verify that the contact information listed for you is valid g. Criteria points support the reasons or indications. It lists changed subsets 2015 interqual criteria summary of. These criteria do not replace clinical judgment, and we recognize that they require.
Interqual aligns payers and providers with actionable, evidencebased clinical intelligence to support appropriate care and foster optimal utilization of resources. Blue cross blue shield of massachusetts is an independent licensee of the blue cross and blue shield association. Select a priority level based on your timing needs d. Inpatient and surgical care milliman careguidelines. Hospitals frequently use level of care criteria as an objective tool to help make decisions regarding whether an individuals condition is severe enough, or the services provided are intense enough, to be admitted to a specific level of care. You will see a confirmation message pop up and receive a confirmation email shortly after i. Wellcare clinical practice guidelines reference expert professional and clinical society recommendations, ensuring that the guidelines contain the highest level of evidencebased content. Mckesson interqual level of care criteria 20 ringbound january 1, 1900 by mckesson author see all formats and editions hide other formats and editions. Interqual medical necessity criteria are applied to all mental health cases, medical policies, dom administrative code and milliman care guidelines. American psychiatric association 168th annual meeting may 18, 2015. Jan 17, 2017 interqual evidencebased criteria and technology solutions help improve clinical decisionmaking and care management across the medical and behavioral health continuums of care.
The conditionspecific format presents evidencebased interventions that are specific to the condition and help to costeffectively improve outcomes. Interqual criteria are objective and specific to better help ensure the most appropriate care and more consistent, defensible decisionmaking. Rather than being based on diagnosis, they consider the level of illness of the patient and the services required. Interqual mobile offers you aroundtheclock access to the latest and most accurate clinical content at your fingertips. Interqual level of care criteria the interqual level of care products cover the. Level of care determinations will be based on interqual criteria and.
This new criteria allows for appropriate admission of medically complex patients with comorbid conditions who may not otherwise meet criteria for the primary condition alone. Eating disorders, j am acad child adolesc psychiatry 2015. Care guidelines from mcg provide fast access to evidencebased best practices and care planning tools across the continuum of care, supporting clinical decisionmaking and documentation as well as enabling efficient transitions between care settings. New and enhanced content is a hallmark of the interqual annual release. Level of care criteria interqual and internal medical policies to milliman moderate care guidelines. An enhanced digital version of the interqual books, interqual mobile offers you all the benefits of a printed book without the confines of a single annual release, giving you aroundtheclock access to the latest and most accurate clinical content at your fingertips.
Criteria points are clinical statements that refer to test results, medications, symptoms, findings, monitoring, medical management, functional status, and prescribed therapies. Interqual level of care acute criteria pediatric 2004. Charting guidelines attending physicians must write a progress note daily on a patients chart not just cosign a residents note. To access your interqual content for use with interqual mobile, you will need to enter your interqual criteria licensing credentials. On the description line enter interqual view 2015 f. Interqual mobile offers you aroundtheclock access to the latest. Jun 21, 2007 cms does not mention interqual or any other level of care criteria in either definition. Please note that the these are suggestions based on interqual criteria and milliman criteria used by medicare, tenncare tenncare and most of the major payers. Evidencebased criteriaguidelines utilization management. If 14 above are not met, beacons national medical necessity criteria would be appropriate. Interqual level of care criteria help healthcare organizations assess the safest and most clinically appropriate care level for more than 95% of reasons for admission. Care guidelines for evidencebased medicine mcg health.
The foundation of the interqual solution is our marketleading clinical criteria, which helps payers and providers consistently apply evidencebased clinical decision support. Access your interqual criteria on your tablet or smartphone with a few swipes of your finger. Implementation of the 2017 interqual criteria health. Level of care criteria interqual criteria are set of measurable, clinical indicators, as well as diagnostic and therapeutic services, that reflect a patients need for hospitalization. Level of care criteria new york 622017, 101717 cmmc approved 3 3 inpatient psychiatric services are expected to significantly improve the members psychiatric condition within a reasonable period of time so that acute, shortterm 24hour inpatient medicalpsychiatric and nursing services will no longer be needed. Included in the 2015 interqual release is new acute adult level of care criteria to address comorbid. Interqual 2015s acute adult level of care criteria helps promote care quality and minimize the administrative delays, costs, and inefficiencies. Mcg senior care strategy consultant, india watson, rn, msn, bsn. Retain all agreements, books, documents, papers and medical records. Interqual level of care criteria help healthcare organizations assess the safest and most clinically appropriate care level for more than 95 % of reasons for admission. Medical necessity in considering coverage for any level of care, all elements of. Level of care criteria interqual and internal medical policies to. Level of care criteria assist organizations in assessing the clinical appropriateness of patients admissions and continued stays across the continuum of care.
Selecthealth medical criteria sets are outlined in each medical policy. Substance use lab testing criteria is in interqual behavioral health criteria. Interqual level of care criteria are available for. Interqual level care criteria skip to main search results amazon prime.
Price new from used from ringbound, january 1, 1900 please retry. Interqual level of care acute criteria pediatric 2004 on. Interqual level of care criteria description interqual acute adult criteria help determine the appropriateness of admission, continued stay and discharge at acute care facilities for patients who are age 18 or older. Apr 16, 2020 access your interqual criteria on your tablet or smartphone with a few swipes of your finger. Interqual level of care criteria 2010, longterm acute care, adult. Please specify if you would like to receive the criteria via mail, fax, or email. When the member has coverage for this care the skilled nursing facility admission criteria must be met for eligibility. Final mic report 2011 connecticut general assembly ct. It is important to understand that the criteria reflect clinical interpretations and analyses and cannot alone either resolve medical ambiguities of particular situations or provide the sole basis for definitive decisions.
Members who require this level of care but do not have coverage must pay for the service themselves. Interqual andor milliman training for individuals case. Sm registered and service marks of the blue cross and blue shield association. The reference to the mckesson interqual level of care criteria edition updated from 2014 to 2015. The richness of clinical detail allows for consideration of. Vermont medicaid provider manual vermont medicaid portal. Included in the 2015 interqual release is new acute adult level of care criteria to address comorbid conditions on admission for patients with heart failure and copd. Are hospitals bound by interqual criteria when determining.
If guidelines are met, the requesting provider is notified of the. Change healthcare, llc interqual guidelines are available to. This week we successfully resolved a technical issue that had delayed the implementation of the 2017 criteria past our originally stated october 1 target date. Issued february interqual criteria clinical content is a synthesis of evidencebased standards of care, current. Implementation of the 2017 interqual criteria as a reminder, health partners plans uses mckessons interqual criteria as a guideline for making medical necessity determinations.
At the acute level of care, changed responder criteria. Interqual level of care criteria 2010, acute care, adult. For example, the interqual criteria sets for see a random page in this book. Clinical practice guidelines are also used to guide efforts to improvement the quality of care in our membership. Interqual quick reference guide for admissions quick source learning quick source learning quick reference guides and computer based training, quick source interqual isd criteria. If the level of care is not substance use related, change healthcares interqual behavioral health criteria would be appropriate. Interqual level of care criteria the interqual level of care products cover the continuum of care. Interqual actionable evidencebased criteria portfolio. Enter your login information then type the applicable policy in the search field. Interqual level of care acute criteria pediatric 2004 ringbound january 1, 2004 see all formats and editions hide other formats and editions. Interqual level of care criteria change healthcare. Apr 24, 2014 i have searched high and low for a class on interqual but have been unable to find one so far. Review of clinical information to determine if it meets criteria for medical necessity, and level of care.
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