utilization review
Also written as: UR — Utilization Review
A systematic process of evaluating the medical necessity, appropriateness, and efficiency of healthcare services and treatment plans.
Full Definition
Utilization Review is a quality management process used by healthcare organizations and insurance companies to determine whether healthcare services are medically necessary, appropriate for the patient's condition, and provided in the most cost-effective setting. In behavioral health, UR involves reviewing treatment plans, length of stay, level of care decisions, and treatment outcomes against established criteria and evidence-based guidelines. The process includes prospective review (before treatment), concurrent review (during treatment), and retrospective review (after treatment). UR aims to ensure patients receive appropriate care while controlling costs and preventing overutilization of services. Reviewers may be nurses, physicians, or other qualified professionals who use standardized criteria and clinical guidelines to make determinations about coverage and continued treatment authorization.
Usage
Usage note: Can be abbreviated as UR. Often used in conjunction with terms like 'medical necessity' and 'prior authorization'.
In Context
- "The utilization review nurse requested additional documentation to support continued inpatient stay." — Insurance authorization note
- "UR criteria indicated that the patient met medical necessity for intensive outpatient treatment." — Level of care determination