CommercialPrior AuthHigh impact
2025 InterQual Criteria Implementation
Blue Cross Blue Shield of North Dakota·ND·Prior Authorization
Effective date
Aug 1, 2025
We identified it
Jun 19, 2026
Summary
Blue Cross Blue Shield of North Dakota is implementing updated 2025 InterQual criteria for prior authorization reviews effective August 1, 2025. The policy includes specific organizational exceptions for inpatient admissions, residential treatment centers, substance use facilities, and urgent home health evaluations that may bypass standard InterQual requirements under certain conditions.
Action Required
By August 1, 2025: Prior authorization team must access updated 2025 InterQual criteria through the Availity Essentials portal under Authorizations & Referrals section. Update prior authorization workflows to incorporate the new organizational exceptions: allow clinical documentation up to 3 days prior to admission for RTC/LTAC/SNF/Acute Rehab; implement bypass protocols for substance use facilities with appropriate medical oversight capabilities; and establish urgent home health evaluation exception process for complex discharges within 24-48 hours. Train staff on new criteria to avoid authorization denials.