We'll use 2025 InterQual criteria starting June 2
Beginning June 2, 2025, we’ll use 2025 InterQual® criteria to make medical necessity determinations on prior authorization requests to ensure our members are getting the right care, at the right place and at the right time.
Why are we updating to 2025 InterQual?
InterQual is nationally recognized as an industry standard for evidence-based medicine criteria, ensuring appropriate care. These criteria are regularly updated to reflect the most recent evidence-based and clinical standards.
What authorization types are affected?
As a result of this transition, the following authorization types will be based on modifications to 2025 InterQual criteria, for all plan types:
- Level of care (LOC): Acute Adult*
- LOC: Acute Pediatric*
- LOC: Inpatient Rehabilitation
- LOC: Subacute/Skilled nursing facility
- LOC: Home Care Q&A
- LOC: Long-Term Acute Care
- CP: Durable Medical Equipment
- CP: Procedures
- Medicare: Post Acute & Durable Medical Equipment
- Medicare: Procedures
- Behavioral health (BH): Adult and Geriatric Psychiatry
- BH: Child and Adolescent Psychiatry
- BH: Substance Use Disorders
- BH: Services
*Several criteria set revisions based on best practices and available evidence