The criteria used to make determinations is reviewed annually by MCHP, including researching clinical and medical evidence. The criteria are updated as needed. These Criteria are for informational purposes only and as such, it is not an authorization, certification, explanation of benefits or a contract.
Receipt of benefits is dependent on the satisfying the terms and conditions of coverage. Eligibility and benefit coverage are determined by the terms of the member’s plan in effect on the date the services are rendered.
- Change Healthcare InterQual® Level of Care Criteria is used for all inpatient length of stay determinations (Adult or Pediatric), medical and behavioral health.
- MCHP uses Change Healthcare InterQual® Care Planning Criteria: Procedures, to determine the medical necessity of surgical procedures for Adult and Pediatric requests.
- Change Healthcare InterQual® Care Planning Criteria: Imaging, is used to determine the medical necessity of imaging requests.
- Change Healthcare InterQual® Durable Medical Equipment (DME) is used to determine the medical necessity of DME requests.
To view the Change HealthCare InterQual® Medical/Surgical Criteria go your MyChart. The InterQual® Medical/Surgical Criteria is under the Resources section of the Menu.