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MCG Chosen as UM Clinical Criteria Vendor

June 28, 2022

Milliman Care Guidelines (MCG) has been chosen as our acceptable use criteria vendor to review utilization management (UM) requests beginning February 1, 2023.

Our 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 allow us to provide more visibility to UM criteria at the point of care, better support interoperability, and reduce administrative burden for providers. Additionally, MCG’s medical policy structure, customization options, and clinical guidelines promote consistent standards of care and reduce clinical variability.

We will be working with MCG’s education support team to develop customized training. More information about how to access this presentation 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 Blue Shield of Northeastern New York medical directors review and approve authorization requests will not change.

While Highmark will be transitioning to MCG in February 2023, we understand not all providers will either choose to change to MCG or be able to change to MCG by February.

Please note: It is not necessary for providers to change from their current licensed criteria vendor; however, MCG’s Switch Program will be able to assist those who may be interested.

We will continue to work with you during this transition and provide additional information in the coming months.

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