As previously announced, UnitedHealthcare transitioned to evidence-based InterQual® clinical criteria to support utilization management, beginning with dates of service on May 1, 2021. The transition includes nearly all our commercial, Medicare and Medicaid benefit plans. The transition to InterQual is another example of how we invest in our clinical capabilities to make our processes more efficient and consistent.
Our transition to InterQual clinical criteria will help shorten turnaround times for clinical decisions. It will help support consistency in our decision-making and help us respond to inquiries and review requests more quickly, efficiently and transparently. There’s no change to how you submit prior authorization requests. You can find more information on the process at UHCprovider.com/priorauth.
Viewing the InterQual criteria
To help you understand determinations based on the InterQual clinical criteria, we give you access to a read-only version of the criteria at UHCprovider.com/policies > Clinical Guidelines > InterQual Clinical Criteria. The tool is for reference only, and you can use it before you submit a request or after we’ve given you a determination.
After you sign in with your One Healthcare ID, you can search the InterQual subset criteria by product, keyword or medical code. Click on HELP in the right corner to find InterQual’s instructions for conducting a review.
- You’re not required to use InterQual products within your own organization
- Your processes shouldn’t be affected and your daily work shouldn’t be disrupted
- The transition to InterQual is part of our internal technology structure
- Delegated entities may use different evidence-based clinical guidelines
- A small number of UnitedHealth Group entities, including Rocky Mountain Health Plans and Sierra
Health Services Inc., won’t transition to InterQual for their members at this time
We’re here to help you
If you have questions, please contact your Provider Advocate or UnitedHealthcare network representative. Or call Provider Services at
the number on the member’s ID card.