TO: Gateway Network Providers

DATE: March 10, 2008

Gateway's Utilization Management Department assesses the medical appropriateness of services using nationally recognized criteria. In April 2008 Gateway will apply the McKesson InterQual Criteria for authorization requests from all lines of business when authorizing the delivery of healthcare services to plan members. 

The criteria are developed by McKesson's clinical research staff which includes physicians, registered nurses and other healthcare professionals. Many of McKesson's clinical staff holds advanced degrees in case management certification. The clinical content is reviewed and validated by a national panel of clinicians and medical experts including those in community and academic practice settings, as well as within the managed care industry throughout the United States. The clinical content is a synthesis of evidenced-based standards of care, current practices and consensus from licensed specialists and/or primary care physicians. McKesson's InterQual Criteria is a licensed product that is research-based and enables non-physician reviewers to make reliable and consistent evaluations about the medical appropriateness of requested services. 

In addition to those Medicaid and Medicare requests presently being assessed using the McKesson InterQual criteria, in April 2008, the criteria will also include acute care, skilled nursing facilities, home health care, outpatient and inpatient rehabilitation, and chiropractic services.

These requests will continue to require an authorization by Gateway's Utilization Management Department. The information required to process an authorization is not expected to change.

In addition to the services listed above, Gateway's Medicare Assured^SM line of business will also utilize InterQual criteria for behavioral health inpatient, partial hospitalization, psychological and neuropsychological testing requests for children, adolescents, adults, geriatrics, as well as chemical dependency requests. 

As always, if a request does not meet the criteria requirements, a Gateway Physician will review for a medical necessity determination. An opportunity to discuss the request with the Physician advisor will also be provided to the ordering physician. If you would like additional information about the McKesson InterQual Criteria, please contact your Provider Relations Representative, the Utilization Management Representative or Physician. 

Gateway's Utilization Management Department may be contacted at the following phone numbers:

Pennsylvania Medicaid:                      1-800-392-1146 menu option 3
Pennsylvania Medicare Assured^SM:     1-888-447-4375 
Ohio Medicare Assured^SM:                 1-888-447-4375

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