Highmark Transition to MCG Health Happening in February

Effective February 6, 2023, Highmark will incorporate MCG Health clinical guidelines into Highmark’s criteria of clinical decision support, replacing Change Healthcare (InterQual). This change is being made to align the clinical review processes and platforms for Highmark health plans.

As a result of implementing this process, Highmark will be using MCG utilization criteria to review authorizations ranging from acute through outpatient.

Access to MCG criteria will be made available through the NaviNet® provider portal. Training tools will be available on the Highmark Provider Resource Center and webinars will be offered in January.

Frequently Asked Questions

Q: Who is MCG Health?
A: MCG Health provides unbiased clinical guidance that gives healthcare organizations confidence in their patient-centered care decisions.

Q: Why is Highmark making this change?
A: Highmark’s transition from Change Healthcare (InterQual) to MCG will more fully support our Living Health strategy and allow us to upgrade our Utilization Management (UM) capabilities and automation.

Q: How does Highmark use clinical criteria for authorization decision-making?
A: Initial reviews of authorization requests are performed by Highmark registered nurse reviewers with clinical experience. They utilize the following criteria, guidelines, and policies to review the medical necessity of the requested services:

  • MCG Health Clinical Criteria
  • Highmark Medical Policies
  • Highmark Medicare Advantage Medical Policies
  • American Society of Addiction Medicine (ASAM) Criteria
  • New York Only: Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria
Additional information about authorization decision-making can be found on Highmark’s Provider Manual Chapter 5, Unit 1 - Care & Quality Management: Care Management Overview.

Q: What clinical services are in scope change?
A: 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 (psychiatric levels of care that require authorization)
    • Note: Highmark will continue to use ASAM guidelines for Substance Use Disorder levels of care that require authorization.
  • MCG’s Medicare Compliance Solution is coming later in 2023.
    • The Medicare Compliance Solution incorporates Medicare National Coverage Determination (NCD) guidelines, National Coverage Analysis (NCA) guidelines, and Local Coverage Determination (LCD) guidelines to support clinicians with time savings and better documentation practices.
Q: Where will MCG’s guidelines be located?
A: Highmark’s medical policies and MCG’s evidence-based clinical criteria will be available within MCG's AutoAuth workflow when submitting prior authorizations.

Q: What is the best way to assure enough clinical information is sent with the initial request for Highmark to process an authorization?
A: The following information is valuable to consider as you are submitting your authorization.

  • Check all clinical values in the MCG guidelines that apply to represent the full clinical condition of the patient.
  • Attach relevant supporting documentation with the request, i.e., a history and physical, labs, imaging, prior discharge instructions (if a readmission), etc.
  • Most importantly, wait until the treatment plan is established and test results completed to submit the inpatient authorization request (typically within 48 hours of an urgent admission).

Q: What Highmark members will be affected?
A: Any Highmark members who receive services that require authorization utilizing MCG Health Clinical Criteria in the review of medical necessity are in scope.

Q: Who do I call with questions?
A: Contact your Provider Account Liaison, if applicable, or Highmark’s Provider Service Center .