Northeast Health Care Quality Foundation
The QIO for Maine, New Hampshire and Vermont
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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, 2007, NHCQF will begin use of the 2007 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: is acutely ill, requires and will receive hospital services that can only be provided on an acute hospital inpatient basis; and will receive Medicare covered services. 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 2007 Next Chapter: Issuance of Hospital Notices
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