InterQual AutoReview
Utilization management software
Health care software
Health care operations software
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What is InterQual AutoReview
InterQual AutoReview is a utilization management module that automates clinical review and medical-necessity determinations using InterQual criteria. It is used by health plans and provider organizations to support prior authorization, concurrent review, and discharge/level-of-care decisions. The product focuses on rules-driven automation, exception-based work queues, and documentation of decision rationale tied to evidence-based criteria.
Criteria-based review automation
The product applies InterQual medical-necessity criteria to automate portions of utilization review workflows. This can reduce manual chart review for straightforward cases and route exceptions for clinician review. It also standardizes how criteria are applied across reviewers and sites.
Audit-ready decision documentation
AutoReview records the criteria logic and supporting data used to reach a determination. This helps organizations demonstrate consistency and traceability for internal audits and external reviews. It also supports more consistent communication of rationale to stakeholders involved in authorization and care transitions.
Exception-based work management
The workflow emphasizes routing of non-conforming or incomplete cases to appropriate staff rather than treating all cases the same. This supports prioritization and workload balancing for utilization management teams. It aligns with operational models that combine automation with clinical oversight.
Dependent on data quality
Automation effectiveness depends on the availability and structure of clinical and administrative data feeding the review. Missing, delayed, or unstructured documentation can increase exception rates and manual follow-up. Organizations often need upstream documentation and interface improvements to realize full value.
Integration and configuration effort
Deployments typically require integration with EHRs, case management systems, and authorization platforms to capture required data elements. Criteria mapping, workflow configuration, and user-role setup can be time-consuming. Ongoing maintenance may be needed as criteria updates and organizational policies change.
Criteria scope may not fit all
InterQual criteria may not align perfectly with every payer policy, specialty program, or local clinical pathway. Organizations may still need supplemental rules, manual review, or policy overlays for certain services and populations. This can limit end-to-end automation for complex or niche use cases.
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/
