MCG vs InterQual Criteria Compared

At the level a buyer or an appeals writer can verify: publisher, ownership, cadence and product architecture. MCG Health is part of the Hearst Health network and markets its independence from payer and provider ownership as a feature. InterQual is published by Optum, a UnitedHealth Group company. Both refresh annually. Both are organised into content lines covering different care settings - MCG names Inpatient, Ambulatory, Behavioral Health, Chronic, Transitions of Care and Post Acute lines plus a Medicare compliance line; InterQual's recent releases add navigator and automation modules around the core criteria. What is not verifiable from outside, because both products are proprietary and paywalled, is whether one set is systematically stricter than the other for any given service. Any page claiming to answer that from public sources is not doing so from public sources.

No. CMS addressed this directly in the CY2024 Medicare Advantage final rule after commenters asked it to prohibit proprietary criteria outright. CMS declined to ban them but held that 'use of these tools, in isolation, without compliance with requirements in this final rule at Sec. 422.101(b), (c), and Sec. 422.566(d), is prohibited.' It went further on the substantive limit: 'MA plans may not use InterQual or MCG criteria, or similar products, to change coverage or payment criteria already established under Traditional Medicare laws.' In practice that means where an NCD, an LCD, a statute or a payment regulation already sets the criterion - the inpatient admission payment criteria, the SNF, home health and IRF rules - the commercial criteria set cannot be used to make it narrower.

Only when Medicare coverage criteria are 'not fully established', a phrase 42 CFR 422.101(b)(6)(i) defines in three ways: where additional unspecified criteria are needed to interpret or supplement general provisions in order to determine medical necessity consistently; where an NCD or LCD explicitly allows coverage beyond its listed indications; or where there is no applicable Medicare statute, regulation, NCD or LCD at all. In the first case the plan must demonstrate that the additional criteria 'provide clinical benefits that are highly likely to outweigh any clinical harms, including from delayed or decreased access to items or services'. The internal criteria must also be based on current evidence in widely used treatment guidelines or in clinical literature that the rule defines fairly tightly - large randomised trials, large prospective cohort studies, or large systematic reviews or meta-analyses.

Yes, where it relies on internal coverage criteria. 42 CFR 422.101(b)(6)(ii) requires the plan to make three things publicly accessible: the internal coverage criteria in use together with a summary of the evidence considered during their development; a list of the sources of that evidence; and an explanation of the rationale supporting adoption. Where the criteria supplement or interpret a general provision, the plan must additionally identify which general provisions are being supplemented and explain how the additional criteria produce clinical benefits highly likely to outweigh clinical harms. This is the practical lever for a provider disputing a denial: if a plan cites internal criteria, the rule contemplates that those criteria and their evidence base are findable.

A utilisation management committee, under 42 CFR 422.137. It must be led by the plan's medical director. Its composition is specified: a majority of members must be practising physicians, at least one practising physician must be independent and free of conflict relative to the organisation and the plan, at least one must be an expert in the care of elderly or disabled individuals, and members must represent a range of clinical specialties. Since 1 January 2024 an MA plan 'may not use any UM policies and procedures for basic or supplemental benefits' unless that committee has reviewed and approved them. The committee must review all UM policies at least annually against traditional Medicare coverage decisions and current clinical guidelines, must document its reasoning in writing and make it available to CMS on request, and must remove UM requirements for services that no longer warrant them.

Because they are proprietary and paywalled, and reproducing or paraphrasing them would be both a licensing problem and a reliability problem. Neither MCG nor Optum publishes its decision rules openly; access runs through a customer licence and a login. That constraint is worth stating plainly rather than working around, because it also shapes what you can and cannot do in an appeal: you can cite the federal limits on how criteria may be applied, and you can require a plan to identify and support the criteria it relied on, but you generally cannot quote the vendor's text back at them from a public source. Any comparison that claims to show side-by-side criteria content is either reproducing licensed material or inventing it.

No. InterQual is presented and released under Optum, which states that it is a UnitedHealth Group company, and Optum's own release announcements are issued in Optum's name. Change Healthcare is no longer the operating brand for the product. This matters for two practical reasons: correspondence, appeals and contract documents should name the current entity, and searches that still return Change Healthcare pages are returning stale results rather than current product information.

The choice is usually constrained rather than free, because the criteria set that matters most in a dispute is often the one the payer uses, not the one the hospital licenses. Where a hospital does have a genuine choice, the evaluation criteria that are actually testable are: coverage of your case mix and care settings, including behavioural health and post-acute if you operate them; how well the product integrates with your EHR and existing UM workflow; how the vendor keeps its Medicare compliance layer current against NCDs, LCDs and payment rules; measured inter-rater reliability among your own reviewers after training, which you can test; and what the licence permits in appeals and in external review. Ownership structure is a legitimate but secondary factor, and it cuts in MCG's favour on positioning rather than on any demonstrated difference in criteria content.

The specific provisions cited here - 42 CFR 422.101(b), 422.137 and 422.566(d) - are Medicare Advantage rules and do not automatically govern commercial plans, Medicaid managed care or traditional Medicare fee-for-service review. Medicaid managed care and commercial utilisation review are governed by separate federal and state frameworks, and state utilisation review law varies considerably, including on which criteria sets may be used and what must be disclosed on denial. Treat the MA rules as the clearest and best-documented constraint on commercial criteria use, and check your state's utilisation review statute and your specific payer contracts before assuming the same limits apply elsewhere.