Blue Cross of Idaho Logo

Express Sign-on

Thank you for registering with Blue Cross of Idaho

If you are an Individual or Family Member under age 65, please register here.

If you are an Medicare or Medicare Supplement member, please register here.

New Options for Affordable Health Insurance

PAP 279

Clinical Criteria


Provider Administrative Policy

Section
Care Management
Policy Date
October 2013
Status/Date
New/October 2013
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

Clinical Criteria

Clinical Criteria - Utilization Management

Blue Cross of Idaho makes our clinical review criteria available to providers upon request. Locally developed criteria and medical policies are posted on the plan's website under Medical Policy Reference Manual.

Blue Cross of Idaho has licensed the following 2013 edition of the McKesson InterQual® Level of Care Criteria. Physicians may request a copy of clinical criteria we use to make coverage decisions for patients by calling or faxing the Medical Quality Management Department (MQM) at 208-286-3482 or faxing a request to 208-387-6676.

Blue Cross of Idaho's MQM clinicians (registered nurses and licensed clinical social workers) use this information, along with clinical judgment and the needs of the individual member and characteristics of the local delivery system, including the availability of the proposed services within the network service area, to make a coverage decision. The MQM clinical staff has the authority to approve services based on medical necessity. If the staff decides the service is outside the scope of the appropriate professional staffs' authority, the case is referred to the medical directors for a determination.

Blue Cross of Idaho medical directors are the only representatives with the authority to deny authorization or payment for services based on medical necessity or appropriateness. They will give the requesting provider and member alternatives for denied care or services based on the criteria set used or individual case circumstances.

In making determinations based on contract benefit exclusions/limitations, the member contract, the MQM staff uses the Evidence of Coverage (EOC) and Group Services Agreement as references.

Inpatient Certification

Blue Cross of Idaho has incorporated the 2013 edition of the McKesson InterQual® Level of Care Criteria (Acute Pediatric; Acute Adult) as the basis of the inpatient certification process which is objective and evidenced based. In addition, we apply the InterQual® criteria when reviewing the appropriateness of admissions for inpatient rehabilitation services, admissions to skilled nursing facilities, and for home healthcare services. It is the practice of most of our contracting hospitals to utilize the InterQual® criteria during their internal utilization review process. Physicians my review the InterQual® criteria at any contracting hospital or by contacting the Blue Cross of Idaho MQM department at 208-286-3482.

Outpatient/Other Certification

Blue Cross of Idaho has incorporated the 2013 edition of the McKesson InterQual® Level of Care Criteria for Observation, Adult and Pediatric Care Planning Procedures, Durable Medical Equipment and Molecular Diagnostics Criteria to determine medical necessity for outpatient services. We use Medicare guidelines like the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) to determine the prior authorization of services and durable medical equipment for Medicare/Medicaid product lines.

Behavioral Health Levels of Care Clinical Criteria

The Blue Cross of Idaho Behavioral Health (BH) Utilization Management Program has incorporated the 2013 edition of the McKesson InterQual® Level of Care Criteria, Behavioral Health Chemical Dependency & Dual Diagnosis (Adult & Adolescent); Behavioral Health Psychiatry (Adult, Child, Adolescent, Geriatric); and Residential and Community-Based Treatment (Adult, Adolescent & Child) as the basis for determining medical necessity for the services being requested. The BH Utilization Management clinician selects the level of care criteria based on the member's age and the level of care requested by the facility or provider.

As part of the Blue Cross of Idaho Utilization Management Program, all criteria are reviewed and approved by the Blue Cross of Idaho Advisory Committee and Behavioral Health Advisory Committee, at least annually.


Policy History

Date Action Reason

Search for Policies

Policy Feedback