MCG Guidelines: Transparency Portal

MCG Guidelines

Please visit the MCG Transparency Portal above for a full list of the following guidelines:

  • Ambulatory Care
  • General Recovery Care
  • Inpatient & Surgical Care
  • Recovery Facility Care

Utilization Management (UM)

Designed to benefit both providers and patients by putting patients on the right path to the right care in the right setting

Backed by nationally recognized evidence-based guidelines, UM is committed to ensuring services are properly utilized by patients. We help you ensure that patients receive high-quality, medically necessary care that is supported by a robust provider network which grows and changes to meet patients’ medical, cultural, language, and geographic needs.

We aim to provide services that are:

  • Covered under the plan benefit
  • Medically necessary
  • Appropriate to the patient’s condition
  • Rendered in the appropriate setting
  • Professionally recognized standards of care

We conduct reviews such as:

  • Prior authorization – to eliminate the need for unnecessary services helping reduce denials and ensuring patients are taking the proper path to care
  • Concurrent review – Performed during the course of treatment
  • Retrospective review – Assessing the appropriateness of completed care
  • Benefit determinations using medical necessity criteria and transition of care programs