About InterQual®
InterQual content is the most widely used, evidence-based clinical decision support for case 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 Change Healthcare LLC, is used in many of Wellmark’s medical review processes to support the medical necessity of health care services.
How to access InterQual criteria
The InterQual criteria is available to clinicians by logging into Provider portal and submitting an authorization request.
Note: You will need to be assigned access to log into Provider Portal. Your designated security coordinator (DSC) can assign this role.
To access InterQual resources:
- In state providers: Use the InterQual Criteria Tool for information.
- Out of state providers: Submit a request through the SmartSheets Request Form
The InterQual® criteria is updated annually to allow for the most current criteria to be utilized by Health Services in their decision making process. The Wellmark authorization table will be updated accordingly when the updated criteria is implemented. The InterQual® Criteria for all services requiring prior approval will be effective for any requests initiated on or after each yearly implementation date regardless of date of service.
Wellmark Utilization Management criteria
Wellmark has developed custom Utilization Management (UM) criteria sets for certain acute inpatient level of care hospital admissions. Standard InterQual criteria is used if all the listed UM Criteria sets do not apply to a member’s condition.