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Medical Necessity Criteria

Our registered nurses (Case Management Coordinators) use McKesson’s InterQual criteria as their main source of decision support. AmeriHealth began licensing the InterQual criteria for acute and subacute rehabilitation services in 2000. AmeriHealth also uses the InterQual guidelines for acute and home-care settings, as well as support for procedure and durable medical equipment decisions.

The InterQual decision-support tools (criteria) are well recognized and have widespread acceptance within the provider and payer environments. The tools are developed in annual cycles using a rigorous methodology that has been refined over the course of 30 years. This includes an extensive review of the latest evidence-based medical literature with consensus building among clinical experts from a pool of more than 700 consultants representing a wide range of specialties and sub-specialties.

For information regarding the InterQual clinical decision support tools, please visit their website at www.mckesson.com. Information regarding a specific case guideline can also be obtained by calling 856-802-3109.

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