📋 InterQual BH Software

InterQual Behavioral Health Software
InterQual BH Criteria Built In

CriteriaIQ is the only clinical authorization tool that applies the exact criteria from InterQual BH BlueCross BlueShield Medical Policy InterQual BH (effective April 17, 2025) inside Kipu EMR. InterQual BH Adult primary criteria plus all four NYS additional criteria sections — with specific lettered sub-criterion citations for every finding.

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InterQual BH Policy InterQual BH — April 17, 2025

The exact two-step framework from the policy document

CriteriaIQ implements InterQual BH Criteria exactly as written — not a loose interpretation. The April 2025 revision changed the additional criteria requirement from all four to ONE. CriteriaIQ reflects this change.

1
InterQual BH Adult Primary Criteria (ALL THREE required)
Applied first. All three domains must be addressed simultaneously.
⚠
Risk of Harm

Suicidal ideation level, homicidal ideation, self-harm risk, danger to others. Rated Meets / Partially Meets / Does Not Meet from psychiatric notes and nursing assessments.

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Functional Status

Ability to perform ADLs, social functioning, occupational role impairment. Rated from biopsychosocial, H&P, and recent clinical progress notes.

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Co-morbidity

Medical, psychiatric, and SUD co-morbidities and their interactions. Rated from H&P, psychiatry notes, medication list, and lab results.

2
Additional NYS Criteria — ONE of four required
Applied only when InterQual primary criteria are not fully met. Per April 17, 2025 revision.
CriteriaIQ identifies which of the four criteria applies and cites the specific lettered sub-criterion from Policy InterQual BH.
[1] High/Severe Environmental Stress

8 specific sub-criteria including: (a) unavoidable substance use in living environment, (b) physical/sexual abuse, (c) chaotic/violent family environment, (d) homelessness, (e) chronic disabling pain, (f) inability to carry out ADLs, (g) traumatic life event, (h) severely overwhelmed with responsibilities

[2] Non-Existent or Little Support

3 sub-criteria: (a) few sources of support, (b) current supports unwilling/unable to assist, (c) unwilling or refusing to utilize existing supports

[3] Poor/Partial Treatment Response

Historical or present treatment resulting in inability to maintain gains, or persistent functional deficit after structured treatment. Residential: also partial remission or no sustained recovery despite treatment.

[4] Inability/Limited Engagement

Inability to understand disease, refusal or lack of insight preventing recovery actions, anger/emotional paralysis/paranoia preventing treatment gains. Residential: also ambivalence, poor impulse control, or barriers from secondary conditions.

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Concurrent review timelines

Policy InterQual BH prohibits concurrent review during the first 30 days of inpatient admission (unless OMH-designated). CriteriaIQ enforces the correct review windows: day 2-13 for inpatient, week 2 for residential/PHP, weeks 2-3 for IOP.

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All 4 LOC types covered

CriteriaIQ applies the correct Policy InterQual BH criteria for the appropriate level of care: Inpatient, Residential, Partial Hospital Program (PHP), and Intensive Outpatient Program (IOP). Each LOC has its own criteria thresholds.

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InterQual-only appeal letters

Appeal letters cite exclusively InterQual BH domain language and InterQual BH Criteria criteria. The specific LOC section (A/B/C/D), the criterion number [1-4], and the lettered sub-criterion are cited in every appeal.

FAQ

InterQual & InterQual BH policy questions

What changed in InterQual BH Criteria on April 17, 2025?
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The April 17, 2025 revision changed the additional NYS criteria requirement from requiring ALL FOUR criteria to be met to requiring only ONE (1) of the four criteria. This is a significant change that makes it easier to authorize continued care for patients who don't fully meet InterQual BH Adult primary criteria. CriteriaIQ reflects this April 2025 language exactly.
Does CriteriaIQ work for New York State facilities only?
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InterQual BH Criteria applies to services rendered within New York State. CriteriaIQ's InterQual BH analysis is most directly applicable to NYS-based treatment facilities or providers treating InterQual BH members. The InterQual primary criteria (risk of harm, functional status, co-morbidity) are applicable across payers.
How does CriteriaIQ cite the specific NYS sub-criterion?
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CriteriaIQ identifies which of the four additional NYS criteria is most supported by the clinical evidence, then identifies the specific lettered sub-criterion (e.g., "Section A.1.d — Homelessness") from the policy document and cites the clinical evidence from the Kipu chart that supports it. This level of specificity is essential for concurrent review and appeal letters.
Can CriteriaIQ help with InterQual appeals after a denial?
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Yes — the appeal tab in the InterQual overlay generates a formal appeal letter that cites InterQual BH Adult primary criteria domains met with specific clinical evidence, the InterQual BH Criteria additional NYS criterion that applies with the specific lettered sub-criterion, and relevant NYS Insurance Law requirements. The letter also references the April 17, 2025 policy revision.

InterQual BH analysis with
exact policy citations

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