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Medicaid Milliman Clinical Guidelines (MCG) Rollout

At ‘Ohana, we value everything you do to deliver quality care to our members – your patients – and ensuring they have a positive healthcare experience.

Effective April 30, 2019, ‘Ohana is adopting Milliman Clinical Guidelines (MCG) criteria for Medicaid Inpatient Physical Health (Inpatient Admissions, Post-acute Care, Skilled Nursing Facility, Inpatient Rehabilitation, and Long-term Acute Care), Outpatient Physical Health, and Outpatient Behavioral Health Services. The new criteria will replace the current Change Healthcare/McKesson InterQual™ criteria.

MCG Health’s innovative software offers system-wide solutions that ensure appropriate and cost-effective care for your patients – our members.

Recent changes in healthcare law require payers to navigate increasingly complex regulations to maintain compliance. Clinical decision support from MCG lets you and ‘Ohana craft care plans by using the latest medical data with those regulations in mind.

In addition, MCG solutions let ‘Ohana and providers share documentation and automate prior authorizations. This cuts administrative costs, which lets you more efficiently improve the member's journey to better health. 

More than 80% of the U.S. payer market uses MCG guidelines and software. They help you provide our members with better health care experiences – saving time and money. MCG tools can help reduce length of stay in acute and post-acute settings as well as 30-day hospital readmissions, which can improve independent quality ratings (HEDIS®, CMS Stars).

For questions or information regarding ‘Ohana policy and procedures, visit our website at www.wellcare.com/hawaii. You can also contact Customer Service at 1-888-846-4262, Monday through Friday from 7:45 a.m. to 4:30 p.m.

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Last Updated On: 1/10/2019