CommercialPrior AuthMedium impact
Highmark transitions to MCG health clinical guidelines
Blue Cross Blue Shield of Kansas·KS·Provider News
Effective date
Feb 13, 2023
We identified it
Jun 19, 2026
Summary
Effective February 13, 2023, Highmark replaced Change Healthcare (InterQual) clinical guidelines with MCG Health guidelines for clinical decision support and review processes. This affects prior authorization and medical necessity determinations for Highmark members.
Action Required
Immediately: Billing team should review current prior authorization processes for Highmark members to ensure compliance with new MCG Health clinical guidelines instead of InterQual criteria. Update staff training materials and reference documents. Use Availity or member ID card contact information for benefit verification and prior authorization requirements under the new guidelines.