Interqual
Clinical decision support
Health care software
Health care operations software
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What is Interqual
InterQual is a clinical decision support criteria set used by health plans, hospitals, and utilization management teams to support medical necessity determinations and level-of-care decisions (for example, inpatient vs. observation, and post-acute placement). It is commonly used in prior authorization, concurrent review, discharge planning, and appeals workflows. The product is delivered as evidence-based criteria content and is typically integrated into payer and provider utilization management systems rather than used as a standalone EHR.
Standardized medical necessity criteria
InterQual provides structured criteria that organizations use to apply consistent rules for level-of-care and medical necessity decisions. This standardization supports repeatable reviews across reviewers and sites. It is widely used in utilization management contexts where auditability and consistency are required.
Supports UM and care transitions
The criteria are designed for workflows such as prior authorization, concurrent review, discharge planning, and post-acute care placement. This aligns the tool with operational needs beyond point-of-care diagnosis and treatment guidance. It can help teams document rationale for decisions and support communication between payer and provider stakeholders.
Integrates into enterprise workflows
InterQual is commonly implemented within payer and provider utilization management platforms and can be embedded into review workflows. This makes it practical for high-volume review operations where users need decision support inside existing systems. Integration also supports reporting and governance processes tied to authorization and denial management.
Not a full clinical reference
InterQual focuses on medical necessity and level-of-care criteria rather than broad diagnostic and treatment guidance. Organizations still typically require separate clinical reference content for bedside decision-making and medication knowledge. This limits its role as a general-purpose clinical decision support tool.
Implementation and change management
Embedding criteria into utilization management workflows often requires configuration, integration work, and reviewer training. Criteria updates can also require operational change management to keep policies, templates, and reviewer practices aligned. These factors can extend time-to-value for organizations with complex UM processes.
Potential payer-provider friction
Because the criteria are frequently used in authorization and denial workflows, adoption can be associated with disputes over interpretation and documentation requirements. Providers may view criteria-driven decisions as administrative burden if workflows are not well designed. Organizations often need clear governance and appeals processes to mitigate this.
Seller details
Optum, Inc. (UnitedHealth Group) — Change Healthcare business
Eden Prairie, Minnesota, USA
1972
Subsidiary
https://www.optum.com/
https://x.com/optum
https://www.linkedin.com/company/optum/
