New objective criteria and AI-enabled technology improves transparency, and advances value-based care
(March 25, 2025) – Optum is proud to announce the release of InterQual® 2025, a significant milestone in our goal to deliver high-value, evidence-based content and technology solutions. For nearly 50 years, payers, providers, and government agencies have trusted InterQual to support their organizations in providing appropriate care and managing resources efficiently.
“The 2025 release reaffirms our commitment to developing evidence-based and objective criteria to support clinical decision making,” said John Kontor, M.D., senior vice president, clinical technologies, Optum Insight. “By integrating the latest clinical research and AI-enabled technology, we are empowering health care providers in the delivery of appropriate, efficient, and cost-effective care.”
InterQual 2025 updates improve care delivery and utilization management (UM) processes with:
Data-driven patient setting determinations
- Procedural care is increasingly shifting from inpatient to outpatient settings. InterQual 2025 helps organizations in navigating this transition by providing updated setting determinations using code-level benchmarks, providing more accurate and detailed guidance.
AI-enabled insights and automation
- The new AI-enabled case stratification solution, Case Intelligence, identifies the likelihood of inpatient admission and recommends next steps based on customized workflows. This helps UM teams prioritize reviews and optimize physician advisor time.
- Optum’s medical review automation solution, InterQual® AutoReview, has expanded to cover 90% of condition-specific admission reviews, helping reduce administrative burden, increase efficiency and enhance review accuracy.
Personalized patient communications
- Optum’s Decision Reasons solution provides easy access to content for payers to communicate why a service may not be clinically appropriate, aligned with evidence-based criteria. The content has been expanded to provide more empathetic and personalized communication.
Enhanced support for payers and providers
- The new InterQual Community provides clinical resources and support for payers and providers to improve collaboration through a one-stop forum.
- On-demand education courses developed by American Society of Addiction Medicine (ASAM) help organizations access training directly from the medical society for utilizing the ASAM Criteria® in utilization reviews.
- The InterQual® Certified Reviewer program certifies staff who demonstrate appropriate application of the InterQual criteria, helping organizations develop quality reviewers and enhance clinical decision-making.
InterQual 2025 is available in all cloud applications, allowing users to evaluate and enable the new criteria seamlessly.
The ASAM Criteria is a registered trademark of the American Society of Addiction Medicine.