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QIO TRANSMITTAL SERIES ISSUE: Criteria
- Printable
pages NHCQF
utilizes InterQual ISD®
(Intensity of Service/Severity of Illness/Discharge Screens) Criteria and
InterQual ISP ® (Indications
for Surgery and Procedures) Criteria in the conduct of review for Medicare
review activities. NHCQF’s licensure agreement with InterQual allows for
annual updates to the criteria.
Effective August 1, 2006, NHCQF will begin use of the 2006 version of
the InterQual ISD and ISP criteria.
You will be notified of the effective date of any future updates. Because of the licensing/copyright
restrictions associated with the use of these criteria, NHCQF is not
permitted to distribute the criteria to hospitals. If you wish to purchase InterQual Criteria, you may contact
McKesson/HBOC, InterQual Products Group, at 1-800-582-1738. NHCQF’s Case Review Specialists use criteria as
retrospective screening tools. All
determinations about the medical necessity of an admission or procedure are
made by NHCQF Physician Consultants in accordance with our standard review
process. This process allows for
input from the hospital and attending physician before a final determination
is made. Please remember that the
criteria are not intended to provide absolute guidelines for the necessity of
an admission or procedure. There are
cases that will “meet criteria”, but be inappropriate inpatient admissions.
Likewise, there are cases that will not “meet criteria”, but will be
appropriate inpatient admissions. The
determining factor for an “appropriate” admission of a Medicare beneficiary
to a hospital should be the determination by the admitting physician and
concurrence by the hospital that the beneficiary:
Retrospective QIO
review, in accordance with Medicare guidelines, is the official Medicare
determination. NHCQF encourages hospitals to use some type of criteria in
performing utilization review. Denial
letters from NHCQF can be used as supplemental checks to see if hospital
utilization decisions are on target. June
2006 Next
Chapter: Issuance of Hospital Notices |
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Copyright © 2005 Northeast Health Care Quality Foundation, all rights
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