Insurance Terms

Utilization Review is considered to be the review of how certain medical services are requested and performed. The review typically involved pre-review, or pre-authorization; concurrent review, or inpatient evaluation of care and needs; and retrospective review, or the larger historical picture of how physicians, labs, or hospitals handle their patient populations.

Most HMOs have written standards for what items are reviewed, and what might be considered appropriate for amount, time, and sources of evaluation and treatment. An Independent review organization will also perform utilization review functions.

References

• Understand the nuances of utilization review and utilization mangement
• Medical Case Management Best Practices