Utilization Review Standards 2025

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Steps in Utilization Management Verify the patients coverage and eligibility of the proposed treatment. Collect the patients clinical information to determine the level of care needed and if the proposed treatment is medically necessary. Approve the treatment if criteria are met; deny it if not.
Types of UM: Prior Authorization. The prior authorization, or pre-auth, is done before a clinical intervention is delivered. Concurrent Review. The concurrent review takes place while the patient is receiving care while admitted to a facility. Retrospective Review.
There are three activities within the utilization review process: prospective, concurrent and retrospective. Prospective review includes the review of medical necessity for the performance of services or scheduled procedures before admission.
The most effective utilization management strategies focus on four core components: risk minimization, quality assurance, patient education, and in-depth review. In managing risks, the goal centers around reversing disease processes through early intervention and preventive health measures.
There are three types of utilization reviews: Prospective review: determines whether services or scheduled procedures are medically necessary before admission. Concurrent review: evaluates medical necessity decisions during hospitalization. Retrospective review: examines coverage after treatment.
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People also ask

Utilization review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary. All employers or their workers compensation claims administrators are required by law to have a UR program.
Certified Professional Utilization Review (CPUR) is a certification program that aims to credential and certify individuals who have knowledge and skills in performing utilization review in healthcare settings.

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