Utilization Review Definition

Utilization Review (UR) is a process used by healthcare insurance companies and providers to evaluate the medical necessity, appropriateness, and efficiency of healthcare services and treatments provided to patients. The goal of UR is to ensure that patients receive necessary care while controlling costs and maintaining quality. During utilization review, trained healthcare professionals, such as nurses or physicians, review patient medical records and treatment plans to determine if they meet established clinical guidelines and insurance coverage criteria.

UR may involve pre-authorization before certain medical services are provided, concurrent review during hospital stays, and retrospective review after services are rendered. UR helps insurance companies manage healthcare expenses by preventing unnecessary or excessive treatments and ensuring that treatments align with evidence-based practices and medical necessity criteria. It also serves to protect patients by promoting appropriate care and identifying opportunities for improved care coordination and efficiency within the healthcare system.