BCBSND continues to utilize Change Healthcare’s InterQual® criteria sets. BCBSND has received updated criteria (2021 Release Criteria) and has started using version 2021 criteria for dates of service September 1, 2021 and later.
InterQual exceptions can be made to reflect organizational needs such as legislative or geographic differences. BCBSND does identify the below organizational exceptions for primary reviewers. These exceptions will be reviewed annually with InterQual version updates.
- Episode Day Criteria – Partial Hospital Program (PHP), Residential Treatment Center (RTC), Long Term Acute Center (LTAC), Subacute/Skilled Nursing Facility (SNF), Acute Rehab admission
- Exception: BCBSND recognizes an episode day as a calendar day, which typically begins at 12 a.m. For evening admissions (e.g., after 6 p.m.), Episode Day 1 may represent the admission day (6 p.m.–11:59 p.m.) and the following hospital day
- Clinical Used for Episode Day 1 PHP, RTC, LTAC, Subacute/SNF, Acute Rehab admission
- Exception: In addition to clinical received on date of admission, we will accept clinical obtained up to 3 days prior to admission date. Clinical information obtained greater than 3 days prior to admission will not be utilized by BCBSBD primary nurse reviewer for initial determination.
- ABA supervision
- Exception: Due to access and geographic barriers, some ABA facilities may only employ Board Certified Behavior Analyst (BCBA) and do not have behavior specialists providing care. If a BCBA provides all direct treatment for the case and does not have a direct services professional to supervise, the supervision requirement will be waived. Documentation will be needed that the BCBA provides all care.
- Substance abuse partial hospital program (PHP) – “Discharge or transfer from a controlled environment within last 24 hours.”
- Exception: To ensure access to PHP and account for discharged from a controlled environment, BCBSND will allow discharge from a controlled environment and admission to PHP on the next program day.
- Urgent Home Health-Initial Evaluation
- Exception: Discharges from inpatient hospital or Long-Term Acute Care (LTAC) facilities with an urgent request to complete a home health evaluation within 24-48 hours of discharge due to the medical complexity of the patient, can be allowed by nursing staff without InterQual review based on conversation with the receiving facility regarding medical need.
When the primary reviewer determines the medical necessity is not supported by the criteria, the case is sent to secondary review. Secondary review is performed by a physician or like specialty. The physician can utilize the documentation provided as well as scientific evidence, professionally recognized standards of health care and expert opinion to make a determination on the case.