CurrentPremera BluecrossPolicy N/A

Services Reviewed Using InterQual Criteria

This administrative guideline explains that the Plan uses InterQual evidence‑based criteria to review medical and behavioral health services (and selected DME, procedures, and specialty pharmacy) for medical necessity; it is intended for providers and applies to the Individual market.

Policy Summary

PayerPremera Bluecross

PolicyServices Reviewed Using InterQual Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 4, 2026

Next Review DateN/A

Key ActionProviders must consult InterQual criteria as the evidence‑based standard used by the Plan when requesting coverage and verify member benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manyInterQual modules listed

RELATEDRelated policies

AdministrativePolicy type

IndividualApplies to

Coverage Criteria and Scope

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InterQual review applies: The Plan uses InterQual criteria to determine medical necessity for the listed modules and services (acute adult, acute pediatric, behavioral health, durable medical equipment (DME), procedures, rehabilitation, specialty pharmacy/subspecialty Rx, LTAC, SNF, home care, and related modules).

Specific clinical entry, continued stay, and discharge criteria are defined within InterQual and are not reproduced here.

Certain services previously reviewed under InterQual have been removed from InterQual review and are now covered or reviewed under their specified standalone medical policies. Examples in the policy history include removal of outpatient procedures and DME effective Feb. 5, 2021, and later removals that moved services to separate policies (for example, Negative Pressure Wound Therapy moved to policy 1.01.508; implantable cardioverter defibrillator insertion moved to policy 7.01.44; and multiple procedures such as shoulder arthroscopy/arthrotomy, electrophysiology testing, and endovascular repair for AAA were reassigned to their respective policies with effective dates noted in the history).

This guideline functions as a review tool: it maps services to the InterQual evidence‑based criteria that the Plan uses to determine medical necessity but does not itself enumerate every condition that would be considered not medically necessary. InterQual determinations define whether a requested service meets medical necessity under the member’s benefit; providers must consult the applicable InterQual module and the member’s benefit booklet or customer service for plan‑specific limits.

Provider Actions and Authorization

Prior Authorization

Prior Authorization via InterQual

Certain services require prior authorization and are reviewed using InterQual modules (acute adult/pediatric, procedures, DME, specialty pharmacy subsets, behavioral health, LTAC, home care, subacute/ SNF). Providers must submit requests through the Plan's authorization process and reference the applicable InterQual module for the service being requested.

Affected areas include: Acute care modules, Behavioral Health, Durable Medical Equipment (DME), Home Care, LTAC, Procedures, Specialty Rx (oncology and non‑oncology), Subacute/Skilled Nursing Facility.

Denial Risk

Denial Risk When InterQual Criteria Not Met

If requested services fail to meet the applicable InterQual medical‑necessity criteria, coverage may be denied. Providers should be aware that meeting documentation and benefit verification requirements does not guarantee approval if InterQual criteria are not satisfied.

Denials possible when InterQual criteria are not met.
Appeals and further review options follow Plan procedures documented elsewhere in the policy.

Documentation Required

Documentation and Benefit Verification

Providers must verify member benefits and submit complete, clinical documentation that supports how the requested service meets the specific InterQual criteria applied. Documentation should include relevant clinical history, diagnostic results, prior treatments, and any other information cited in the InterQual module.

Verify member coverage and any plan limitations before submitting an authorization request.
Include clinical notes, test results, prior therapy attempts, and pertinent vitals/measurements referenced by InterQual.
Be prepared to supply additional records on request to support medical necessity determinations.

Step Therapy

Step Therapy (Not Specified)

No specific step‑therapy rules are detailed in this guideline. When step therapy or prior authorization sequencing applies for specialty drugs, the Plan reviews specialty medication requests using the applicable InterQual specialty pharmacy modules and any plan‑specific pharmacy management rules.

No discrete step therapy pathways are specified in this document.
Specialty drug subsets (oncology and non‑oncology) are reviewed via InterQual modules; pharmacy benefit rules may also apply and should be checked with the member's pharmacy benefits.

Background

InterQual is an evidence‑based set of clinical criteria used by the Plan to evaluate medical necessity across levels of care and service types, including acute adult and pediatric care, behavioral health, procedures, durable medical equipment, rehabilitation, specialty pharmacy, and other specialty modules. This administrative guideline lists the InterQual modules the Plan applies for review and notes that the specific entry, continued‑stay, and discharge criteria are defined within InterQual and are not reproduced in this document.

Definitions

InterQual criteria (definition)

DefinitionInterQual — an evidence-based set of clinical criteria the Plan uses to evaluate medical necessity and guide coverage decisions across levels of care, procedures, durable medical equipment, and specialty pharmacy.

ScopeUsed to review medical and behavioral health services, care planning, complex care management, DME, procedures, and specialty pharmacy for medical necessity.

Role in coverage determinationsInterQual criteria are applied to determine whether listed services are medically necessary; specific entry, continued-stay, and discharge criteria are defined within InterQual and not reproduced in this guideline.

Provider guidanceThis guideline directs providers to consult InterQual as the evidence-based standard when requesting coverage; it is intended for providers and does not by itself list specific not medically necessary conditions.

Interaction with benefit verificationMember benefit booklet or customer service must be consulted to determine specific plan limits; InterQual determines medical necessity within those benefit constraints.