InterQual Flashcards
What is InterQual and what is its primary purpose in healthcare?
InterQual is an evidence-based clinical decision support criteria system used by healthcare providers and payers to guide utilization management. It provides objective, standardized criteria to assess the medical necessity of treatments and the appropriate level of care, helping ensure patients receive the right care in the right setting  . In essence, InterQual aligns clinicians and insurers on when a service is justified based on clinical evidence, promoting quality care while avoiding unnecessary costs.
What are the core benefits of using InterQual criteria?
The core benefits of InterQual include more consistent and defensible decision-making, improved care quality, and optimized resource utilization. By using InterQual’s evidence-based guidelines, organizations can reduce administrative burden (fewer denials and appeals due to clearer criteria), enhance collaboration between payers and providers (everyone works from the same clinical standard), and ensure patients get appropriate, medically necessary care  . Overall, it helps achieve better patient outcomes with no unnecessary services, supporting value-based care goals.
In what use cases is InterQual typically applied?
InterQual is used in a variety of utilization management and care review scenarios. Common use cases include prior authorization reviews (evaluating if a proposed procedure or service meets medical necessity criteria), concurrent review of hospital stays (to decide if a patient continues to meet criteria for inpatient care), and level-of-care determinations (such as deciding inpatient vs. observation status)  . It’s also applied in post-acute care planning, where criteria help determine if a patient qualifies for services like rehab, skilled nursing facility care, or home health after discharge . Essentially, whenever a question of “Is this healthcare service warranted for this patient?” arises, InterQual criteria can be consulted to inform the decision.
How does InterQual help distinguish between different levels of care, such as inpatient vs. outpatient?
InterQual criteria include specific severity of illness and intensity of service measures that help reviewers decide if a patient’s condition merits an inpatient admission or can be managed outpatient. For example, the criteria will list clinical findings (like vital sign instabilities, lab values, or treatment needs) that must be present to justify inpatient care . If those evidence-based thresholds aren’t met, the patient might be treated under observation or outpatient status instead. This ensures that inpatient status is reserved for those who truly need hospital-level care, preventing unnecessary hospital admissions. InterQual also aligns with guidelines like Medicare’s two-midnight rule, further clarifying when a stay should count as inpatient for compliance . By clearly delineating these requirements, InterQual helps hospitals and insurers make consistent decisions about the appropriate care setting.
What distinguishes InterQual from other clinical guidelines or tools?
InterQual’s distinguishing features are its rigorous evidence basis, comprehensive scope, and broad industry acceptance. The content is developed through a systematic review of medical literature and is continually updated by clinical experts, which ensures the criteria reflect the latest best practices  . It covers a wide range of clinical areas (medical, surgical, behavioral health, and beyond, across all care settings), whereas some guidelines might focus only on specific conditions or settings . Additionally, InterQual is widely used by both providers and payers – including government agencies – which means decisions based on InterQual are more readily accepted and trusted across the healthcare system . This broad adoption (thousands of hospitals and health plans) and integration into UM software workflows also set it apart as a leading tool for utilization review. In short, InterQual is known for its robust, peer-reviewed content and its ability to streamline decision-making by providing one common reference for determining medical necessity.
