InterQual Criteria
CHANGE HEALTHCARE INTERQUAL CRITERIA SUBSETS AND SMARTSHEETS
InterQual aligns payers and providers with actionable, evidence-based clinical intelligence to support appropriate care and foster optimal utilization of resources.
InterQual® Criteria and SmartSheets
When we receive a request for authorization or prior approval, our utilization review clinicians use Change Healthcare’s InterQual® criteria to determine if the services and level of care are clinically indicated. If the criteria are met, the request is approved; if the criteria are not met, the request is reviewed by a physician.
We encourage providers to use Change Healthcare’s InterQual SmartSheets to submit prior authorization requests for the procedures in the categories below. Use of SmartSheets is recommended because they provide us with the information, we will need to expedite your request. We accept SmartSheets for the following procedures.
| Back Surgery (SmartSheet Category: Neurosurgery) | |
|---|---|
| Anterior Cervical Discectomy and Fusion (ACDF) | Hemilaminectomy (Laminotomy) +/- Discectomy, Lumbar |
| Discectomy, Percutaneous, Lumbar | Laminectomy (with Fusion), Cervical |
| Fusion (with Laminectomy), Cervical | Laminectomy (with Fusion), Lumbar |
| Fusion (with Laminectomy), Lumbar | Laminectomy (with Fusion), Thoracic |
| Fusion (with Laminectomy), Thoracic | Laminectomy, Cervical |
| Fusion, Cervical Spine | Laminectomy, Lumbar |
| Fusion, Lumbar Spine | Laminectomy, Thoracic |
| Fusion, Thoracic Spine | |
| Hemilaminectomy (Laminotomy) +/- Discectomy, Cervical | |
| Hysterectomies (SmartSheet Category: Obstetrics and Gynecology) |
|---|
| Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy |
| Hip and Knee Replacements (SmartSheet Category: Orthopedic – Lower Extremity) |
|---|
| Total Joint Replacement (TJR), Hip Total Joint Replacement (TJR), Knee |