MCG Clinical Guidelines

Highmark uses MCG Health’s evidence-based clinical guidelines to support utilization management decisions. These guidelines help ensure that care decisions are consistent, efficient, and based on the latest medical evidence. 

MCG guidelines support decisions for:

• Inpatient and surgical care
• General recovery care
• Ambulatory care (including procedures, durable medical equipment, prosthetics, orthotics, and supplies)
• Recovery facility care (such as skilled nursing and inpatient rehabilitation)
• Outpatient services
• Behavioral Health Care
• Home Care
• Interrater Reliability
• Medicare Compliance

They are commonly used for decisions such as: 

• Authorization reviews 
• Prior authorization 
• Discharge planning 
• Level-of-care determinations 
• Retrospective reviews

Note: MCG guidelines do NOT apply to delegated services.

Accessing MCG Guidelines

Use our instructional page for details on how to view or access clinical criteria.

To view the guidelines, follow the link below:

Note:

• Clinical criteria used for utilization management decisions related to radiology, cardiology, musculoskeletal, and other services are managed by eviCore.
• The guidelines do NOT apply to the services provided to Highmark Wholecare or Highmark Health Options Medicaid members.

Need help?

For questions about MCG clinical guidelines or access, email us at mcgquestions@highmarkhealth.org