Clinical criteria are rules or standards on which a decision or judgment is made to determine medical necessity. DVHA staff utilizes clinical criteria for making Utilization Review (UR) decisions that are objective and based on sound medical evidence. Adopted criteria include the following:
- InterQual®Criteria:
- DVHA Clinical Criteria; and
- Vermont State Medicaid Rules.
To access InterQual® solution, an evidence-based clinical decision support solution, please log into your vtmedicaid.com account. Once logged in, go to secure options and click on InterQual® solution from the dropdown menu.
Visit the Vermont Medicaid Fee Schedule for the codes that require prior authorization. Excess quantity may require prior authorization.