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Policy Number: 05-06
Effective Date: May 2006
Health Net utilizes McKesson Health Solution's InterQual criteria as a primary source of criteria for medical management decision-making. The InterQual criteria cover the continuum of care, from acute settings through home care and outpatient treatment. The criteria provides Health Net with the following:
The InterQual criteria are developed and revised through a continuous process that combines an comprehensive review of evidenced based medical/behavioral health literature with additional input from more than 700 clinical expert consultants representing a wide range of specialty disciplines and geographic regions. The criteria are also reviewed annually preceding the release of each version of the criteria.
The InterQual criteria is reviewed annually by Health Net's National Medical Advisory Council (MAC) and formally adopted for use in medical management decision-making. MAC may revise InterQual criteria in limited circumstances.
Level of Care Criteria
ISD are used to determine the appropriateness of admission, continued services, and discharge across the continuum of care. ISD uses objective, clinical indicators to determine the proper level of care, based on the patient's severity of illness and service requirements. The ISD criteria set guides decision making for the intensity of service, severity of illness, and discharge screens for acute care. ISD is intended to supplement and support the physician's own knowledge. ISD-AC criteria consist of adult and pediatric criteria.
Care Planning: Indications for Surgery and Procedures
The prior authorization criteria allow determination of the appropriateness of procedures, using known clinical indications that justify the procedure. The criteria ensure that medical decisions are based on the patient's clinical status and service requirements, not diagnosis alone. The criteria help the physician and/or reviewer confirm that all the signs, symptoms and findings that are necessary are documented to support the physician's request for services. The prior authorization criteria include indications for Surgery and Procedures (ISP).
Level of Care Criteria ( Sub-Acute and SN, Home Care and Rehabilitation)
InterQual's Level of Care criteria cover the continuum of care, from acute settings through home care and outpatient treatment. It allows for consideration of an individual patient's severity of illness, co-morbidities, and complications, in the review process in real time. InterQual Criteria sets for inpatient rehabilitation, sub-acute and skilled nursing facilities contain objective endpoints for service. The nurse reviews for discharge or transfer readiness with built-in checkpoints to identify progress, plateau or achievement of goals.