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26-1317 Transition to InterQual Clinical Review Criteria

Date: 11/05/26

InterQual® will be used for behavioral health medical necessity reviews, effective November 15, 2026

Effective November 15, 2026, Wellcare By Health Net (Health Net) will transition behavioral health medical necessity reviews from LOCUS/CALOCUS to InterQual clinical criteria. InterQual is an evidence-based clinical review tool informed by current clinical evidence, nationally recognized guidelines and independent clinical peer review.

This transition supports a more consistent approach to behavioral health medical necessity reviews across lines of business and the use of clinical criteria that are regularly reviewed and updated.

Behavioral health authorization and continued-stay reviews will be evaluated using InterQual criteria. Because InterQual uses a different clinical framework than LOCUS/CALOCUS, the criteria used to evaluate medical necessity will change.

How InterQual differs from LOCUS/CALOCUS

LOCUS/CALOCUS and InterQual use different approaches to evaluating the appropriate level of behavioral healthcare.

  • LOCUS/CALOCUS uses a multidimensional assessment and scoring approach that considers factors such as risk of harm, functional status, co-occurring conditions, recovery environment and response to treatment to help determine the appropriate intensity of services. LOCUS is specifically designed to assess service needs across multiple dimensions and translate that assessment into a recommended level of care.
  • InterQual uses evidence-based, service-specific clinical criteria to evaluate whether the requested service or level of care is clinically appropriate based on the member’s current clinical presentation and treatment needs.

As a result, authorization and continued-stay requests will be evaluated against the applicable InterQual criteria rather than the LOCUS/CALOCUS scoring framework beginning November 15, 2026.

What is not changing

  • Existing authorization submission processes and provider workflows will remain the same.
  • Continue to submit the clinical information required for authorization and continued-stay review requests. Use the appropriate prior authorization request form listed below:
    • Medicare Advantage plans - Inpatient (PDF)
    • Medicare Advantage plans - Outpatient (PDF)

The forms are available at Prior Authorizations.

Questions?

If you have questions about this change, call 844-966-0298.

 

This information applies to Behavioral Health Facilities.



Last Updated: 11/05/2026