Prior Authorization & Clinical Review Criteria

The information below should not be considered your actual policy of insurance. It should be noted that not all of the services listed in the medical policies and criteria may be covered (included) under your existing policy. Please reference your plan or group policy for more specifics or Contact Health Alliance customer service if you have any questions.

*The statistics are applicable to Illinois state-regulated health issuers, but do not apply to employee or employer self-funded health plans (ERISA); healthcare provided under the Workers’ Compensation Act or the Workers Occupational Diseases Act; or state employee, local government, or school district health plans.

Prior Authorization (PA) Lists*

2021 DME List Standard (1/1/2021-12/31/2021)
2022 DME List Standard (1/1/2022-12/31/2022)
2023 DME List Standard (1/1/2023-12/31/2023)
2024 DME List Standard (1/1/2024-12/31/2024)
2025 DME List Standard (1/1/2025-12/31/2025)
2021 PA List Standard (1/1/2021-12/31/2021)
2022 PA List Standard (1/1/2022-12/31/2022)
2023 PA List Standard (1/1/2023-12/31/2023)
2024 PA List Standard (1/1/2024-12/31/2024)
2025 PA List Standard (1/1/2025-12/31/2025)

*The Prior Authorization (PA) lists are applicable to Illinois state-regulated health issuers, but do not apply to employee or employer self-funded health plans (ERISA); healthcare provided under the Workers’ Compensation Act or the Workers Occupational Diseases Act; or state employee, local government, or school district health plans.

This information is current and posted as of January 1, 2025.

Clinical Review Criteria - Includes Links to Outside Agencies

Health Alliance Internal Criteria

Medical Policies

InterQual® Criteria Access

Health Alliance uses medical necessity criteria based on published clinical evidence to make utilization and prior authorization decisions. Use of the InterQual® clinical decision support solution is one of the ways we help our provider partners deliver evidence-based appropriate care. Our aim in sharing these criteria is to provide our provider partners with this reference resource to review coverage criteria for prior authorization requests. This resource is intended to help providers and members better understand our decisions and how they align with current medical evidence.

Participating members and providers with a Health Alliance account can access InterQual® criteria with their Health Alliance account sign-on through this portal. Once signed in, you can search for a specific guideline or use codes or keywords to locate information.

Non-participating members and providers who do not have a Health Alliance account can access InterQual® criteria through this Change Healthcare InterQual Transparency Portal. Note: In order to access InterQual criteria sets you will be required to create a One Healthcare ID at the link provided in order to access information from Change Healthcare. You can search for a specific guideline or use codes or keywords to locate information.

InterQual® criteria and any other relevant information including benefit provisions, other medical criteria, or protocols, used to make a decision, are also available upon request by calling 1-800-851-3379, extension 28927.

American Society of Addiction Medicine (ASAM) Criteria for Substance Use Disorder (SUD)

American Society of Addiction Medicine (ASAM) for Substance Use Disorder