What is InterQual Qualification? How to Get It (Benefits, FAQs)

InterQual is a set of evidence-based criteria and standards that aid in clinical decision-making, utilization management, and care coordination throughout the healthcare continuum.

InterQual aids in selecting a suitable care environment, service, and intervention based on patient-specific clinical requirements and accepted standards of care.

Healthcare organizations receive assistance from InterQual in quality enhancement, cost reduction, and regulatory compliance.

So, if you curious about how to effectively use InterQual and the InterQual Qualification, then you’ve come to the right place.

How is InterQual Developed?

InterQual is developed using evidence-based medicine (EBM) standards; the process is thorough and open to scrutiny.

Evidence-based medicine (EBM) is about integrating clinical skills and patient values with the best available research information to make informed decisions about patient care.

InterQual methodically finds, evaluates, synthesizes, and updates the best available scientific literature on various clinical topics.

InterQual guarantees it develops exhaustive, accurate, and appropriate criteria and recommendations by incorporating expert opinion, clinical practice guidelines, regulatory requirements, and stakeholder feedback.

Once a year, expert physicians and nurses from outside the company gather to examine and enhance InterQual.

The panel evaluates the clinical relevance and application of the criteria and recommendations and their potential impact on patient outcomes and resource consumption to reach its verdict.

This panel also considers novel technologies, therapies, or interventions that change the criteria and recommendations.

More so, the panel adheres to a stringent conflict of interest policy to safeguard the fairness and impartiality of the evaluation.

What are the Benefits of Using InterQual Qualification?

Using InterQual can benefit many people in the healthcare industry, as well as healthcare organizations and patients. Such benefits include:

  • Tailoring treatment to each person’s specific requirements and preferences, thereby improving patient care and clinical results
  • Eliminating or minimizing the use of care that is both harmful to patients and wasteful of resources
  • Facilitating better care coordination and communication by standardizing the terminology and structure used in clinical decision-making across locations and specialties
  • Facilitating conformity to national and international standards and guidelines for accreditation and regulation.
  • Providing consistent measurements and criteria for monitoring performance and growth to ease data gathering and analysis

What is InterQual Qualification Used for?

A variety of formats and several different platforms allow users to access InterQual. You can use the following to access InterQual:

  • Web-based platforms where healthcare providers may enter patient data, review practice guidelines and metrics, run reports, and record their conclusions.
  • Electronic health records (EHRs) or other clinical information systems that integrate InterQual with existing workflows and data sources.
  • Mobile devices or tablets that enable users to access InterQual anytime and anywhere
  • Books and user guides in print format are for those who learn best with physical copies.

The InterQual system is utilized in various ways within the healthcare industry, covering a broad range of applications, including but not limited to:

  • Admission review: To determine if a patient meets the criteria for admission to a specific facility or level of care (such as an observation unit, an acute inpatient unit, a long-term acute care unit, etc.).
  • Continued stay review: To determine whether a patient should remain at a certain level of care or setting or if a change is necessary.
  • Discharge planning: To determine the best place for a patient and the best way to get there, considering their current health, ability, social support, and desired outcome.
  • Prior authorization: To ensure that the service or intervention (such as surgery, a treatment, a test, medicine, a gadget, etc.) is required and appropriate for the patient before providing it.
  • Concurrent review: To track care quality and appropriateness during a patient’s stay or episode of care to ensure the best possible outcomes.
  • Retrospective review: To assess the appropriateness and quality of the treatment after a patient’s stay or episode of care.

How to Get an InterQual Qualification

Healthcare providers license the InterQual product, which is not a certification program for individuals. Therefore, Change Healthcare requires a license before using InterQual in a clinical setting.

Change Healthcare makes various training tools available once you purchase a license to use InterQual in your organization. Some tools include:

  • Webinars and courses that teach you all you need to know about InterQual, from how it’s made to how to use it to what documentation you’ll need to get started.
  • Workshops, either in-person or online, that give participants experience with and feedback on utilizing InterQual in a variety of contexts
  • Instructional materials for the InterQual web portal or application, including manuals and guides on its features and functions

The administrator, organizer, or champion of InterQual at your organization can assist with questions and help in setting up, maintaining, and assessing the tool.

InterQual may make resources such as orientation and training, policies and procedures, quality assurance, and performance improvement available to you.

You can contact Change Healthcare for questions about licensing, pricing, implementation support, training resources, technical assistance, or customer service.

Types of InterQual Qualification/Criteria and Guidelines

InterQual offers a variety of criteria and guidelines for use in various clinical contexts, including but not limited to the following:

1. Level of Care Criteria

Based on clinical requirements and best practices, these criteria help establish the most suitable level of care, setting, service, and action for patients.

This includes short-term care, rehabilitation, long-term care, complicated care, specialist care, and behavioral health.

2. Care Planning Criteria

Patients with complicated or chronic diseases can benefit from tailored care plans, and these criteria can help create and execute them.

The scope encompasses disease management, patient care, and care coordination.

3. Imaging Criteria

Healthcare professionals use these criteria to evaluate diagnostic imaging procedures’ appropriateness and medical need.

This includes radiation treatment, molecular imaging, and diagnostic imaging for adults and children.

4. Procedure Criteria

Medical practitioners use these criteria to evaluate the indications for surgical and nonsurgical treatments.

The criteria include molecular diagnostics, specialized pharmacies, dental work, and operations for adults and children.

Frequently Asked Questions (FAQs) on What is InterQual Qualification? How to Get It

What is InterQual?

InterQual aids clinical decision-making, utilization management, and care coordination across the healthcare continuum by providing evidence-based recommendations and criteria.

Who develops and maintains InterQual?

Change Healthcare, a pioneer in clinical decision support technologies, develops and maintains InterQual.

How is InterQual updated?

Once a year, expert physicians and nurses from outside the company gather to examine and enhance InterQual. The panel assesses the clinical relevance and application of the criteria and guidelines and their potential impact on patient outcomes and resource utilization. This panel takes into account new or developing therapies or interventions because they have the potential to impact the criteria and guidelines.

How does InterQual support quality improvement and performance measurement?

InterQual’s established criteria and metrics enable tracking, evaluating, and comparing care delivery quality and efficiency across multiple locations, providers, patient groups, and periods, promoting quality improvement and measuring performance. InterQual can assist in uncovering improvement areas, care gaps, best practices, standards, and trends. Integrating InterQual with other data analytics tools and dashboards allows it to streamline the information gathering and analysis processes.

How does InterQual promote patient engagement and satisfaction?

InterQual increases participation and satisfaction with the healthcare system by facilitating treatment delivery tailored to each patient’s needs. It aims to involve patients in decision-making, which is why it offers transparent and consistent information about criteria and guidelines, decision reasoning, predicted consequences, and available options.

How does InterQual align with Medicare requirements?

InterQual includes all applicable laws, rules, and policies in its evaluation methodology to comply with Medicare standards. It takes into account Medicare’s Conditions of Participation (CoPs), Benefits Policy Manual (MBPM), National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Quality Improvement Organization (QIO) Program, and Two-Midnight Rule regulations.
InterQual offers crosswalks and references that users can use to find the relevant Medicare requirements.


The InterQual criteria and guidelines aid clinical decision-making, utilization management, and care coordination across the healthcare continuum.

InterQual boosts clinical quality and outcomes cuts down on unnecessary or inappropriate services or interventions, boosts care coordination and communication, aids in meeting regulatory requirements and accreditation standards, and simplifies the collection and analysis of data for healthcare providers, organizations, and patients.

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Chibuzor Ezechie
Chibuzor Ezechie

Chibuzor Ezechie is a professional writer who enjoys writing on a variety of topics, including lifestyle and college applications. His writing career spans more than a year. He is a writer at School and Travel.

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