Update to 2024 InterQual Criteria Sheets, CR 126309

Effective September 12, 2025, we updated InterQual criteria sheets on the MaineCare Health PAS Online Portal. The criteria sheets are used to establish the medical necessity of the requested services. All decisions must align with the most current criteria sheet.

30 Day Transition Period (September 22, 2025 – October 22, 2025)

MaineCare will continue to accept Prior Authorization (PA) requests with the older versions of the InterQual criteria sheets for no more than 30 days; however, the Nurse Reviewer will reference and apply the most current InterQual criteria. The Nurse Reviewer has the option to issue a deferral letter and request the provider complete, sign, date, and submit the most current InterQual sheet, along with any other items necessary to process the PA. 

After 30 Day Transition Period

If a provider submits a PA request with an older version of the InterQual criteria sheet, the Nurse Reviewer will issue a deferral letter and request the provider complete, sign, date, and submit the most current version, along with any other items necessary to process the PA.

A Few Reminders

  • Some InterQual criteria sheets are available on MaineCare’s Health PAS Online Portal, along with MaineCare Supplemental sheets. Nurse Reviewers are expected to review them together. In most cases, the MaineCare Criteria sheet will take priority. The Requesting Provider does not need to include the full criteria sheet in the submission to MaineCare. Instead, the provider may print, sign, date, and submit the first page of the criteria sheet, indicating the relevant clinical scenario number and print only the completed clinical scenario pages that apply.
  • There may be procedure codes listed on the InterQual criteria sheets that are not covered by MaineCare. To be covered, a procedure code must be open and active in MIHMS. To request coverage of a non-covered service or item, please complete and submit a HIPPA Compliant Code Request form for consideration by the Department.

Other PA Updates

The MaineCare criteria sheets reflect current MaineCare Benefits Manual (MBM) citations. Dates of revision are indicated in the footer of the criteria sheets. MaineCare criteria sheets for MBM policies that do not have a revision date indicated are not revised.

For questions, please email Gainwell Provider Services.