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Updated on November 26, 2023. Fact checked by Elaine Hinzey, RD. Hero Images/Getty Images. Utilization review is the process of making sure healthcare services are being used appropriately and efficiently, which is a key component of a value-based approach to paying for health care.
Minimize costs: In response to rising healthcare costs, utilization reviews work to identify unnecessary costs or provide economical alternatives. For example, reviewers often evaluate whether a patient needs intensive care, or if they can move to a trauma unit instead.
Utilization management (UM) criteria are restrictions that payers put on drugs which restrict how and when they will pay for them for their beneficiaries. Criteria can take many forms including step edits in which certain other medications may be required to be tried prior to reimbursement for a particular drug and
Utilization reviews serve to evaluate each patients care before, during and after procedures to ensure they receive adequate care throughout their hospital stay. Some UR nurses may oversee patient discharge and play a role in designing after-care plans, referred to as case management.
Utilization can be defined as the extent to which hospitals are making use of products or services. Many hospitals have historically focused on savings related to pricing and standardization.

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There are three types available: prospective, concurrent, and retrospective. Each of these will have a different utilization review process flowchart and use cases. The first is the prospective review, which happens before treatment starts.

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9792.9. Utilization Review Standards - Timeframe, Procedures

(1) Prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the injured workers condition, not to exceed

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Cal. Code Regs. Tit. 8, 9792.7 - Utilization Review Standards

(a) Effective January 1, 2004, every claims administrator shall establish and maintain a utilization review process for treatment rendered on or after

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Provider Manual

use in conjunction with utilization review and management, grievances, peer review, HEDIS. Studies, Molinas Quality Programs, or claims payment. Providers

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