MedicaidPrior AuthHigh impact
MAB2025062401
Pennsylvania Medicaid (DHS)·PA · Radiology, Orthopedics, Genetics +5 more·Provider Bulletin
Effective date
Jul 18, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is switching from InterQual to Milliman Clinical Guidelines (MCG) for prior authorization screening effective July 18, 2025. This affects prior auth requirements for imaging, DME, prosthetics, genetic testing, inpatient care, and home health services for Medicaid Fee-for-Service patients.
Action Required
By July 18, 2025: Billing team must update prior authorization processes to align with MCG care guidelines instead of InterQual for Pennsylvania Medicaid Fee-for-Service patients. Review and update internal protocols for prosthetics, orthotics, DME over $600, genetic testing, advanced imaging (CT, MRI, PET scans), diagnostic procedures, inpatient admissions, and home health services. Train staff on new MCG criteria requirements. Prior auth requests submitted before July 18 will still use InterQual guidelines.