Medical necessity criteria to support appropriate clinical decisions
In an industry undergoing rapid change, it’s crucial to choose a partner you can trust — one with a shared vision who can help you achieve your strategic objectives. For decades, the InterQual Criteria team has upheld a singular vision of improving patient outcomes by advocating and supporting evidence-based care.
As health care continues to evolve, so will InterQual. We offer regular releases that support those committed to the pursuit of quality outcomes without unnecessary cost.
Our innovative clinical content, technologies, solutions and services have helped our customers:
- Reduce administrative burden
- Enhance payer-provider relations
- Improve care quality
InterQual Criteria is used by:
- More than 4,300 provider organizations
- More than 300 payer organizations
- 100% RACs, MACs, CMS and BFCC-QIOs
Unmatched clinical integrity
Objective, specific and comprehensive clinical content
InterQual Criteria are objective and specific, helping guide consistent, defensible decisions that ensure appropriate, quality care. The portfolio offers comprehensive content that spans the continuum of care for medical and behavioral health.
Rigorous, evidence-based development process
Our highly trained clinical development team performs an unbiased, systematic review and critical appraisal of the evidence using elements of the GRADE approach to help ensure InterQual criteria reflect the best available clinical evidence.
Extensive peer review
Our clinical review panel of more than 1,100 independent, multidisciplinary experts provides extensive, multilevel peer review. Our experts help ensure InterQual Criteria reflect the latest standard of care and best practice.
Content suites available
We provide objective, comprehensive content across the medical and behavioral health continuum of care.
InterQual® Level of Care Criteria
Assess clinical appropriateness with specific criteria for admission, level of care, visit recommendations and maintenance therapy.
InterQual® Behavioral Health Criteria
Criteria help manage the delivery of mental health and substance use care, including initial- and continued-stay level-of-care decisions.
InterQual® Ambulatory Care Planning Criteria
Identify the appropriateness of ambulatory interventions and ensure the appropriate sequencing of care alternatives with these criteria.
Decision Reasons
Effectively and consistently communicate why a service may not be clinically appropriate for a patient/member with this content add-on.
Get started today
We’re here to help you find out how our services could benefit your organization. Fill out this quick form for a representative to contact you.
Related healthcare insights
Article
See how Optum follows the science where it leads, validating the research we find to uphold the clinical integrity of InterQual content.
On-demand webinar
Learn how to streamline efficiency and consistency of the utilization review process.
On-demand webinar
Discover how to meet the latest regulatory requirements for Medicare Advantage plans.
