MCG Clinical Criteria

Highmark incorporates MCG Health evidence-based clinical guidelines into our criteria of clinical decision support.

This fully supports our Living Health strategy and allows 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 clinical guideline structure, customization options, and clinical guidelines more effectively encourage consistent standards of care and reduce clinical variability.

For select services, Highmark uses MCG clinical guidelines. 

MCG care guidelines are licensed by Highmark and used to guide utilization management decisions. These decisions may involve, but are not limited to inpatient review, prior authorization, discharge planning, level of care, and retrospective review.

To view the guidelines, follow the link below.

• For additional assistance, you may reference our MCG Guidelines Access Instructions.

For questions about Highmark and our incorporation of MCG clinical guides, email mcgquestions@highmarkhealth.org.

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 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.