What Is Utilization Review?

Patients who are receiving medical care may hear about a process called utilization review. Utilization review occurs when a health insurance company requests information to approve medical services or treatment.

Significance

• Insurance companies use utilization review, also called utilization management, to examine the need for medical treatment. This process includes reviewing medical files and guidelines for treatment.

Features

• When processing a utilization review, health insurance companies need to follow government guidelines. Most states have guidelines regarding timely decisions, how to notify patients of the utilization decision, the appeals process, staff credentialing and criteria to determine medical necessity.

Cost Effectiveness

• One of the areas that a health insurance company examines is whether the recommended treatment is appropriate given the cost. This helps the insurance company minimize expenditures.

Appeals

• If a utilization review denies a patient medical coverage, the patient can always appeal the decision, and may request the help of a physician or other health care provider. In the appeal process, patients should call their insurance company to notify them that they are beginning the appeal process. If they need continued coverage, they may request an expedited review.