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MCG Clinical Criteria

Effective February 13, 2023, Highmark will incorporate MCG Health evidence-based clinical guidelines into Highmark’s criteria of clinical decision support, replacing Change Healthcare (InterQual).

The shift to MCG will more fully support our Living Health strategy and allow us to transform our utilization management (UM) capabilities with automation that:

  • Creates enhanced visibility to UM criteria at the point-of-care
  • Better supports interoperability and simplification of the authorization process for providers.

MCG’s medical policy structure, customization options, and clinical guidelines more effectively encourage consistent standards of care and reduce clinical variability.

>> View THIS TUTORIAL to learn more about MCG Health.

 

MCG guidelines provide criteria for settings ranging from acute through outpatient, including the following (except for delegated services):

  • Inpatient and Surgical Care
  • General Recovery Care (serves as a companion to Inpatient and Surgical Care guidelines)
  • Ambulatory Care (guidelines for procedures, durable medical equipment, prosthetics, orthotics, and supplies; rehabilitation evaluations, services, and modalities
  • Recovery Facility Care (Skilled Nursing Facility, Inpatient Rehabilitation Facility)
  • Home Care
  • Behavioral Health

 

MCG’s clinical criteria guidelines will NOT apply to the following services:

  1. Radiology and Cardiology Imaging: These are presently managed by eviCore which uses their own medical policy (policies are available on Highmark’s Provider Resource Center)
  2. Tivity’s Physical Medicine Program: Commercial members enrolled in Tivity’s Physical Medicine Program are not affected. It will only include outpatient PT/ physical medicine services performed in the office if managed by Highmark.
  3. Services provided to Highmark Wholecare or Highmark Health Options Medicaid members.

 

Provider Resources

Last updated on 5/1/2023 8:40:37 AM

 

MCG Health, part of the Hearst Health network, is an independent company that provides unbiased clinical guidance that gives healthcare organizations confidence in their patient-centered care decisions.
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