As outlined in the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers (Hospital Manual), we would like to remind you that AmeriHealth uses the clinical criteria and guidelines set by InterQual®, a product of Change Healthcare.
The InterQual clinical decision-support criteria model is based on the evaluation of intensity of service and severity of illness. Covered services for which InterQual criteria may be applied include, but are not limited to, the following:
- home health care
- inpatient hospitalizations
- inpatient rehabilitation
- long-term, acute care facility admissions
- observation
- some elective surgery for inpatient and outpatient procedures
In addition to the above criteria, AmeriHealth requires a consecutive stay period of at least 24 hours for an inpatient admission. For example, if a patient presents to the emergency room at 9:00 p.m. and leaves the facility at 11:00 a.m. the following morning, that is
not considered an overnight stay since the time period did
not reach 24 hours.
Emergency admissions
We apply acute-care guidelines, medical necessity/medical policy criteria, and medical judgment to evaluate medical appropriateness of Emergency admissions. Admissions that do not meet acute intensity of services and severity of illness guidelines are reviewed by an AmeriHealth Medical Director.
Learn more
For detailed information on clinical criteria and guidelines used for admissions, please refer to the
Hospital Manual, which is available for participating providers in the Current Publications section on the AmeriHealth Plan Central page of the NaviNet® web portal (NaviNet Open).
NaviNet® is a registered trademark of NantHealth.