InterQual vs. MCG Criteria: What Physicians Need to Know
Understanding the two major clinical criteria sets used by insurance companies. How InterQual and MCG differ and how to use this knowledge in P2P calls.
What Are Clinical Criteria Sets?
When an insurance company reviews a prior authorization request, they apply standardized clinical criteria to determine medical necessity. The two dominant criteria sets are InterQual (owned by Change Healthcare/Optum) and MCG (formerly Milliman Care Guidelines).
InterQual
Used by: UnitedHealthcare, many Blue Cross Blue Shield plans, and numerous other payers.
How it works: InterQual uses a decision-tree approach. The reviewer inputs clinical data points, and the algorithm determines whether criteria are met. It's binary -- you either meet the criteria or you don't.
Key characteristics:
In a P2P call: When you know the payer uses InterQual, ask which specific InterQual subset was applied. Then address the specific data points that weren't met. "I understand my patient didn't meet the InterQual criterion for [X]. However, the clinical situation warrants an exception because [Y]."
MCG (Milliman Care Guidelines)
Used by: Aetna, Cigna, and many other commercial payers.
How it works: MCG provides clinical indications rather than strict decision trees. There's more room for clinical interpretation and judgment.
Key characteristics:
In a P2P call: With MCG-based reviews, there's more room for discussion. The reviewer has more latitude to consider clinical context beyond strict data points. Present your case with emphasis on the clinical narrative and why your patient's situation warrants the requested service.
Why This Matters for P2P Calls
Knowing which criteria set the payer uses changes your strategy:
| Approach | InterQual | MCG |
|----------|-----------|-----|
| Style | Data-point focused | Narrative focused |
| Key question | "Which specific criterion wasn't met?" | "What clinical factors support an exception?" |
| Documentation | Specific clinical values | Clinical reasoning and context |
| Flexibility | Low -- meet criteria or don't | Moderate -- room for judgment |
How to Find Out
You can ask: "Which criteria set was used for this review?" The reviewer is required to tell you. Some states mandate that the specific criteria be disclosed upon request.
*Preparing for a P2P call? Generate a script that accounts for payer-specific criteria approaches.*