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InterQual® Criteria and SmartSheets™

 

Download PDF of Fact Sheet 

How to Access InterQual® Criteria

  • The InterQual criteria is available to clinicians through SmartSheetsTM on Wellmark.com.
  • The SmartSheets are secure content, so you will need to log in to view.
  • You will need to be assigned the Utilization Management Procedures & DME role to view the SmartSheets.
  • Your designated security coordinator (DSC) can assign this role, if appropriate.
  • View the SmartSheets .
  • DME providers and out-of-state providers can receive the SmartSheets via fax by calling 800-552-3993.

2017 McKesson InterQual Changes

InterQual®content is the most widely used, evidence-based clinical decision support for care management because of its sound clinical logic, which rests on a rigorous, comprehensive development cycle. Refined and proven over 30 years, this development cycle combines systematic, critical assessment of the medical literature by highly trained clinical development teams with feedback from an InterQual clinical panel of 1,100 experts. InterQual® criteria, published by McKesson Health Solutions, is used in many of Wellmark's medical review processes to support the medical necessity of health care services. We are publishing the 2017 annual changes to the criteria for Providers to review prior to implementation. These documents have been modified by Wellmark to reflect clinical revisions only for those items contained on the Wellmark Authorization table.

Additionally, as part of the 2017 InterQual updates, we will be retiring the current Wellmark medical policy and transitioning to InterQual for medical necessity criteria for the below procedure. This procedure is currently already on the Prior Approval list.

  • Gender Reassignment Surgery

To help you prepare for this transition, the InterQual criteria (SmartSheets) for Gender Reassignment Surgery are available for practioners to view. To access the SmartSheets log in to the secure Provider tab on Wellmark.com and look under "Utilization Management Tool and Resources".

 

The 2017 InterQual criteria will be implemented on 10/13/2017. As part of McKesson Health Solutions' content release, coding changes have been made to the following services: Ptosis Repair, BRCA1 and BRCA2 Test, Lumbar Laminectomy, Lumbar, Fusion, Thoracic Laminectomy, Thoracic Fusion, Gender Reassignment Surgery. These changes will be added to the Wellmark Authorization Table. The 2017 InterQual Criteria for all services requiring prior approval will be effective for any requests initiated on or after 10/13/2017 regardless of date of service.


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