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26-1317 Transition to InterQual Clinical Review Criteria
Effective date
Nov 15, 2026
Identified
Nov 5, 2026
Summary
Effective November 15, 2026, Wellcare By Health Net will evaluate behavioral health authorization and continued-stay medical necessity reviews using InterQual clinical criteria instead of LOCUS/CALOCUS scoring. Existing authorization submission processes and forms remain the same, so the practice must still submit the clinical information required for review.
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What to do
Action · 5 steps
01Future transition 2026-11-15: Behavioral health billing team and clinicians should be told that Wellcare By Health Net authorization and continued-stay requests will be evaluated against InterQual criteria rather than LOCUS/CALOCUS, so clinical documentation should reflect current clinical presentation, treatment needs and service-specific information.
02Behavioral health providers and clinical staff: include the clinical information required for authorization and continued-stay requests on submissions, and document the member's current symptoms, functional status and treatment response clearly, since InterQual evaluates the requested service or level of care against the member's current presentation.
03Billing team: keep using the Medicare Advantage inpatient or outpatient prior authorization request forms available at Prior Authorizations on the payer's provider library, and track pending and continued-stay requests in the prior authorization tracker so requests are submitted on time.
04Front desk and scheduling staff: confirm prior authorization status before scheduling behavioral health services for Wellcare members.
05Questions about the change can be directed to 844-966-0298, and the team should watch for further payer notices on InterQual implementation.
Original notice
26-1317 Transition to InterQual Clinical Review Criteria
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.