🧠 Milliman MCG Software

Milliman MCG Mental Health Residential
Authorization Automated

CriteriaIQ applies Milliman Care Guidelines for all three behavioral health levels of care — Mental Health Residential, PHP (Partial Hospitalization), and IOP (Intensive Outpatient) — directly from your Kipu patient chart. SI and IS domain scoring with transparent point rubrics, PHQ-9/GAD-7/PAWS integration, and MCG-specific appeal letters that never reference ASAM.

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MCG Severity of Illness & Intensity of Service

Both domains. Every criterion. Individually cited.

Milliman MCG requires both Severity of Illness (SI) and Intensity of Service (IS) criteria to be met. CriteriaIQ assesses every sub-criterion and cites specific clinical evidence from the Kipu chart for each one that applies.

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Severity of Illness (SI)
What the patient needs — clinical status
Active SI or HI risk requiring monitoring
Up to +20 pts — risk level scored from ideation only through active plan with means
Significant psychiatric symptoms
Up to +20 pts — PHQ-9 ≥15 adds +4 pts; GAD-7 ≥15 adds +3 pts automatically
Functional impairment: ADLs
Up to +10 pts — inability to perform basic activities of daily living, cited from nursing notes
Failed lower level of care
Up to +10 pts — prior treatment at lower LOC with documented clinical regression or insufficient response
Medical co-morbidity complicating treatment
Up to +5 pts — active medical conditions from H&P and nursing notes that impact psychiatric treatment
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Intensity of Service (IS)
What treatment is being delivered
Active psychiatric medication management
Up to +12 pts — specific medications, dosages, and titration from doctor orders in Kipu Med Log
Daily psychiatric monitoring and assessment
Up to +8 pts — structured nursing assessments, daily psychiatry notes, medication response monitoring
Active structured therapeutic programming
Up to +8 pts — individual therapy, group therapy, psychoeducation documented in clinical progress notes
Crisis intervention capacity
Up to +4 pts — 24-hour crisis capacity, CPI-trained staff, seclusion/restraint protocols
24-hour therapeutic milieu
Up to +4 pts — therapeutic community structure, daily group schedule, milieu documentation
How MCG auth probability is calculated: SI criteria contribute up to 60 points (SI → Residential score). IS criteria contribute up to 30 points. Setting appropriateness contributes up to 10 points. PHQ-9 ≥10 adds +2 pts; PHQ-9 ≥15 adds +4 pts. GAD-7 ≥10 adds +2 pts; GAD-7 ≥15 adds +3 pts. Total capped at 100, rounded to nearest 5. A score ≥75 = Meeting Criteria.
MCG Concurrent Review

Continued stay documentation as rigorous as the initial

MCG concurrent reviews require evidence that SI and IS criteria are still met — with clinical trajectory data showing why step-down is premature. CriteriaIQ pulls the most recent 7 days of clinical documents and scores trajectory as improving, plateauing, or regressing.

  • ✓Active SI/IS criteria re-evaluated from recent notes
  • ✓Clinical trajectory scored with trajectory points added to auth probability
  • ✓Discharge barriers extracted from case management notes
  • ✓Treatment plan progress cited per goal from progress notes
  • ✓Estimated additional days and next LOC recommendation
🔄 MCG Concurrent Review — Day 8
MCG Auth Prob (Continued) 78%
Clinical Trajectory Plateauing
Est. Additional Days 5-7
Discharge Barriers Identified:
• Step-down placement not yet confirmed
• Medication titration in progress (Sertraline 50→100mg)
• Family system engagement needed prior to discharge
⚡ Status: Fair — Continued stay justified. Trajectory plateauing with active discharge barriers.
🧠 MCG — PHP & IOP

Milliman MCG criteria for every outpatient level

MCG SI and IS criteria are calibrated differently for PHP and IOP than for residential. CriteriaIQ applies the correct sub-criteria and rubric for each level — never uses a residential template for outpatient.

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MCG — PHP (Partial Hospitalization)

MCG PHP SI criteria require daily monitoring need — active psychiatric symptoms requiring daily assessment, medication initiation needing daily response monitoring, or risk of deterioration without daily structure. IS criteria require 20+ structured hours/week actively being delivered.

PHP Auth Probability Rubric:
Active psychiatric symptoms — daily monitoring need = +25 pts
Daily medication monitoring required = +20 pts
PAWS documented = +10 pts | PHQ-9 ≥15 = +8 pts
Daily psychiatric monitoring (IS) = +15 pts | Daily therapy = +10 pts
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MCG — IOP (Intensive Outpatient)

MCG IOP SI criteria target mild-moderate psychiatric symptoms needing more than weekly outpatient monitoring, medication optimization, PAWS affecting functioning, or inadequate response to standard outpatient. IS criteria require 3+ days/week group/individual therapy and medication monitoring.

IOP Auth Probability Rubric:
Mild-moderate psychiatric symptoms needing structure = +25 pts
Medication monitoring need (more than weekly) = +15 pts
PAWS affecting functioning = +10 pts | Failed outpatient = +12 pts
Group/individual therapy 3+x/week (IS) = +15 pts
All six MCG buttons are included in the Professional plan at $199/seat/month. For facilities with multiple UR staff, the Enterprise plan at $699/facility/month covers up to 15 seats at a single flat rate. Each MCG button has its own SI/IS criteria, auth probability rubric, and framework-pure appeal letter.

Milliman MCG software questions

Does CriteriaIQ produce MCG-specific appeal letters?
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Yes — MCG appeal letters cite only Milliman Care Guidelines language. CriteriaIQ never mixes ASAM criteria, InterQual criteria, or any other framework into an MCG appeal. The letter cites specific SI and IS criteria met with individualized clinical evidence.
Does CriteriaIQ use current Milliman MCG editions?
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CriteriaIQ uses current MCG criteria for Mental Health Residential (MH Residential, Intensive Behavioral Health Services). The AI is trained on MCG criteria language and applies it consistently to every analysis.
How does PHQ-9 factor into MCG authorization?
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PHQ-9 scores from the Kipu Patient Assessments tab are automatically extracted. PHQ-9 ≥10 adds 2 points to the SI domain; PHQ-9 ≥15 adds 4 points. GAD-7 ≥10 adds 2 points; GAD-7 ≥15 adds 3 points. This ensures assessment tool scores directly support authorization.
What if my facility uses MCG for substance use disorders?
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The current Professional plan MCG analysis is built for MH Residential criteria. SUD-specific MCG level of care criteria are on our product roadmap. Contact us if this is a priority for your facility.

MCG authorization in under 60 seconds

Professional plan includes Milliman MCG initial and concurrent review. 14-day free trial.

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