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InterQual® Criteria and SmartSheets™

• InterQual Fact Sheet
• How to Access InterQual Criteria
• 2016 McKesson InterQual Changes

Download PDF of Fact Sheet 

How to Access InterQual Criteria

• The InterQual criteria is available to clinicians through SmartSheets^TM 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.

2016 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 2015 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.

Imaging 2016 Clinical Revisions

Procedures 2016 Clinical Revisions 

DME 2016 Clinical Revisions 

The 2016 InterQual® criteria will be implemented on 8/12/2016. As part of McKesson Health Solutions’ content release, coding changes have been made to the following services: percutaneous neuroblation, cervical laminectomy, thoracic laminectomy and removal and replacement of TJR knee. These changes will be added to the Wellmark Authorization Table. The 2016 InterQual® Criteria for all services requiring prior approval will be effective for any requests initiated on or after 8/12/2016 regardless of date of service.