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Elizabeth M. Whitehorn, Director

Provider Notice issued 11/06/06

Utilization Review – InterQual Behavioral Health Criteria

​To: Participating Hospitals: Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers , and Utilization Review Departments​
​Date: ​November 6, 2006
​Re: ​Utilization Review – InterQual Behavioral Health Criteria

Effective June 1, 2006, the Department of Healthcare and Family Services (HFS) executed a contract with HealthSystems of Illinois (HSI), a federally designated Quality Improvement Organization (QIO), previously known as a Peer Review Organization (PRO), to provide quality assurance and fee-for-service utilization review (UR) in the inpatient hospital setting.  

Review Activity

Under the new contract, HSI will perform Concurrent Review (Certification of Admission and Continued Stay) and Retrospective Prepayment Review of inpatient hospitalizations, if the admitting diagnosis code is one of those selected for review by the department. In addition, HSI will perform Retrospective Postpayment Review on specific categories (codes) randomly selected on a quarterly basis.

 

Change in Criteria

Effective December 1, 2006, at the direction of HFS, HSI’s nurse reviewers will be using the most current version of InterQual Behavioral Health Criteria in their reviews of inpatient behavioral health services. InterQual Behavioral Health Criteria are a set of measurable, clinical indicators, as well as diagnostic and therapeutic services, that reflect a patient's need for hospitalization. HSI’s physician reviewers will continue to use their clinical judgment and experience and current standards of medical practice to render final medical necessity, level of care and quality of care determinations.

 

This change will standardize the criteria sets applied during HSI’s review process. Since many providers are familiar with InterQual criteria, this standardization can help hospital staff provide the essential clinical information needed for utilization review.

 

The InterQual Criteria sets are usually updated and released during the second quarter each year. Prior to implementing new versions of the InterQual Criteria, HSI will send a Provider Update bulletin to all hospital Medicaid liaisons advising them of the implementation date of the new criteria. This Provider Update bulletin will also be posted on HSI’s Web site.

 

Providers wishing to receive e-mail notification, when new provider information has been posted by the department, may register at the following HFS Web site:

http://www.hfs.illinois.gov/provrel

 

Electronic claim submission via the Internet is available by registering on the department’s Medical Electronic Data Interchange, Internet Electronic Claims (MEDI/IEC) System at: <http://www.myhfs.illinois.gov/>. The MEDI/IEC System is available to enrolled providers and their authorized staff, claim submitting agents and payees. During the registration process, you will be given access to specific claim formats based upon your enrollment status with the department.

 

Any questions regarding this notice may be directed to the Bureau of Healthcare Quality Improvement at 217-577-1031.