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Clinical Criteria

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:

  • Change HealthCare InterQual®Criteria:
  • DVHA Clinical Criteria; and
  • Vermont State Medicaid Rules.

Change Healthcare InterQual® Criteria are available to providers on the Vermont Medicaid secure provider web portal. After log-in, look for the link Change Healthcare Smart Sheets under Secure Options. InterQual® Criteria are updated annually.

Visit the Vermont Medicaid Fee Schedule for the codes that require prior authorization. Excess quantity may require prior authorization.