MCG Chosen as Utilization Management Clinical Criteria Vendor

Highmark has selected MCG Health, part of the Hearst Health network and an industry leader in evidence-based guidance, as our acceptable use criteria vendor to review utilization management (UM) requests beginning February 2023.

Highmark’s transition from Change Healthcare (InterQual) to MCG will more fully support our Living Health strategy and allow us to upgrade our UM capabilities and automation.

These capabilities will enable us to provide:

  • Improved Payer-Provider Collaboration: MCG is known in the industry as an independent publisher of clinical decision support widely used by both payers and providers alike (nine of the largest U.S. health plans as well as nearly 2,600 hospitals). Working from a common clinical language, Highmark hopes to enhance communication and reduce payer-provider abrasion.
  • Optimized, Evidence-Based Care: MCG criteria contains thousands of references to the medical literature to provide ample support for appropriate, evidence-based clinical decision-making. MCG updates this content annually as scientific evidence evolves, helping you guide the best care for Highmark members.
  • Efficiency Gains: Highmark will be integrating an MCG solution which will help automate authorization decisions and provide payer-provider communication between the Pega platform and participating hospital EHRs.

Highmark will work with MCG’s education support team to develop training for providers and their staff members. More information will be shared with you as it becomes available.

While the vendor for acceptable use criteria may be changing, the overall process for how Highmark’s nurses and medical directors review and decision authorization requests will not change.