InterQual®
An evidence-based clinical decision support solution to help payers, providers, and government agencies make clinically appropriate medical utilization decisions.
InterQual Overview
InterQual aligns payers and providers with actionable, evidence-based clinical intelligence to support appropriate care and foster optimal utilization of resources. The foundation of the InterQual solution is our market-leading clinical Criteria, which helps payers and providers consistently apply evidence-based clinical decision support. Our Delivery options help reduce administrative cost by streamlining the medical review process. And our Optimization services ensure you get up and running quickly and efficiently and can use InterQual effectively. InterQual AutoReview and InterQual Connect build on this foundation with technology to automate the creation of the medical review and automate the prior authorization process, enabling exception-based UM.
Criteria
InterQual Criteria are objective and specific to better help ensure the most appropriate care and more consistent, defensible decision-making. Our four criteria suites provide comprehensive coverage for medical and behavioral health across all levels of care as well as ambulatory care planning. With an outstanding track record, widespread adoption, and continual enhancement, InterQual Criteria are the standard for evidence-based clinical decision support. Learn about our evidence-based development process.
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InterQual® Level of Care Criteria
Assess the safest and most efficient care level based on severity of illness, comorbidities, complications, and the intensity of services being delivered.
InterQual® Ambulatory Care Planning Criteria
Identify when imaging studies, procedures, DME, MDx tests, specialty pharmacy medications, and specialty referral consultations are appropriate.
InterQual® Behavioral Health Criteria
Manage the delivery of mental health and substance use care, including initial and concurrent level‐of‐care decisions.
Criteria Powered by InterQual®
Content from the Centers for Medicare and Medicaid Services (CMS) and others is converted into our easy-to-use Q&A format to support consistent application of third-party content and improve review workflow and efficiency.
Customize InterQual® Criteria
Incorporate custom content to more closely match your medical and business policies with the Customize tool.
Delivery
We provide a broad range of options to give you easy access to the InterQual Criteria and help streamline your medical review process.
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InterQual® Access Options
We offer a range of InterQual access options to meet any need, from desktop to mobile to cloud.
InterQual® Interactive Medical Review Options
Our Interactive desktop and cloud applications provide access to the InterQual Criteria and help streamline the medical review process.
Optimization
Our dedicated team of clinical, technical, and implementation experts is available to help you at every stage of product rollout and utilization. We provide implementation, education, and consulting services to help you make the most of the InterQual solutions you use, with options that fit your process, schedule, and budget.
Interrater Reliability
Measure how well, and how consistently, your staff applies InterQual Criteria with this web-based tool to help improve usage and quality within your organization.
Education
Our education programs help meet your staff development needs with rigorous and effective training options, from introductory end-user training and physician education to advanced instructor certifications.
Implementation
Benefit from expert knowledge and guidance at the very start. We provide a dedicated team of technical consultants, clinical consultants, and project managers to help you get started with our software solutions. Implementation services are provided for InterQual Review Manager and InterQual Connect.
Consulting
Our professional consulting services can help you obtain the greatest value from InterQual. Through analysis and direct observation, we can help you optimize product performance, improve business processes, identify strategic opportunities, and expand or develop new medical management programs and capabilities.
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Provider Resources
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Case StudyDownload Case Study
InterQual Case Study – Western Maryland Health System
Case study describing how InterQual helped reduce denials as the health system transitioned to value-based care.
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Case StudyDownload Case Study
InterQual Case Study - Florida Hospital Orlando
Case study describing how a collaborative approach in the ED reduces inappropriate admissions.
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WhitepaperDownload Whitepaper
Reducing Denials
Ten steps to reduce denials, win more appeals, and improve hospital performance.
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Fact SheetDownload Fact Sheet
InterQual Evidence-Based Development Process
This flyer describes the rigorous process used to develop and ensure the integrity of the evidence-based InterQual Criteria.
Payer Resources
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Case StudyDownload Case Study
InterQual Case Study - Florida Hospital Orlando
Case study describing how a collaborative approach in the ED reduces inappropriate admissions.
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Fact SheetDownload Fact Sheet
InterQual Evidence-Based Development Process
This flyer describes the rigorous process used to develop and ensure the integrity of the evidence-based InterQual Criteria.