Statewide utilization review program will utilize MCG's independently developed criteria to evaluate services for quality, medical necessity, and appropriateness

HARRISBURG, Pa., Aug. 12, 2025 /PRNewswire/ -- MCG Health, part of the Hearst Health network and an industry leader in technology-enabled, evidence-based guidance, announces that, effective July 18, 2025, the Pennsylvania Department of Human Services has adopted the MCG care guidelines as its new standard for determining medical necessity for services, items, procedures, and levels of care provided to Medical Assistance (MA) beneficiaries. In a bulletin distributed on June 24, 2025, the Deputy Secretary of the Pennsylvania Office of Medical Assistance Programs, Sally Kozak, stated the use of clinical guidelines in the MA program reflects the Department's commitment to "enhance the consistency of review decisions."

The transition applies to all providers enrolled in the MA program who render services in the Fee-for-Service (FFS) delivery system. The Department had historically relied on InterQual Criteria which has been owned by UnitedHealth Group's Optum division since 2022. As of July 18, 2025, the Department will no longer use the InterQual guidelines. Instead, it will rely on MCG care guidelines to support the highest standards of care for its beneficiaries.

MCG care guidelines will be used to screen medical necessity for prior authorization requests related to the following services:

• Prosthetics, orthotics, and supplies
• Durable medical equipment (exceeding $600 in cost or a rental term exceeding three months)
• Genetic medicine, including laboratory services
• Advanced radiology imaging (e.g., CT scans, MRIs, PET scans)
• Diagnostic procedures and tests
• Inpatient and surgical care
• Home care services (e.g., skilled nursing, physical therapy, speech therapy)

Prior authorization requests submitted prior to the July 18 deadline will continue to be reviewed based on InterQual's criteria. However, after that date, all reviews for the above-mentioned services will utilize the latest edition of MCG care guidelines.

"MCG is humbled to be chosen by the State of Pennsylvania's Department of Human Services as the evidence-based guidelines for which it will use to evaluate quality and compliance in their Medical Assistance Program," said MCG Vice President of Government Affairs, Donna Baker-Miller. "Our goal is to lead Pennsylvania's healthcare community to deliver patient-focused care, and this transition brings the state one step closer to achieving that mission."

MCG care guidelines are widely used in the healthcare industry by both providers (hospitals and health systems), payers, as well as many state and federal government agencies. As of 2025, MCG care guidelines are utilized by over 3,000 hospitals, a majority of U.S. health plans, and many state and federal government agencies such as CMS, the U.S. Department of Veterans Affairs, and the Centers for Disease Control and Prevention (CDC).

About MCG Health

MCG, part of the Hearst Health network, provides unbiased clinical guidance that gives healthcare organizations confidence in delivering patient-centered care. MCG's artificial intelligence and technology, infused with clinical expertise, enable its clients to prioritize and simplify their work. MCG's world-class customer service ensures that clients maximize the benefits of licensing MCG solutions – demonstrating improved clinical and financial outcomes. For more information visit www.mcg.com.

About Hearst Health

The mission of Hearst Health is to guide healthcare organizations by delivering essential intelligence and software that improve the quality, safety and efficiency of care. Hearst Health has been innovating with care for more than 40 years, with a commitment to making a lasting positive impact on health. The Hearst Health companies — FDB, Homecare Homebase, MCG, MHK, QGenda and Zynx Health — elevate care by informing and empowering participants across the health journey. To learn more, visit www.hearst.com/hearst-health and follow @Hearst Health on LinkedIn.

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SOURCE MCG Health