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PAP 279

Clinical Criteria

Provider Administrative Policy

Care Management
Policy Date
October 2013
Revised/July 2014
Provider Type(s)
All Providers  


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


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 2014 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 208-387-6936.

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 in 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 2014 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 (Long-Term Acute Care; Rehabilitation; Subacute &  SNF) when reviewing the appropriateness of admissions for inpatient long=term acute care (LTAC) rehabilitation services and admissions to skilled nursing facilities. It is the practice of most of our contracting hospitals to utilize the InterQual® criteria during their internal utilization review process. Physicians may review the InterQual® criteria at any contracting hospital or by contacting the Blue Cross of Idaho MQM department at 208-387-6936 or faxing a request to 208-387-6676.

Outpatient/Other Certification

Blue Cross of Idaho has incorporated the 2014 edition of the McKesson InterQual® Level of Care Criteria for Adult and Pediatric Care Planning for Procedures, Durable Medical Equipment, Molecular Diagnostics, Specialty RX Non-Oncology and Specialty RX-Oncology 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 2014 edition of the McKesson InterQual® Level of Care Criteria, Behavioral Health Substance Use Disorders & 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 is reviewed and approved by the Blue Cross of Idaho Advisory Committee, at least annually.

Policy History

Date Action Reason
July 2014 Revised Updated references to 2014, added language for Specialty RX and phone numbers

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