Utilization 101

At UR Solutions, we believe that knowledge is power. Therefore, we have comprised some basic information about utilization review that we feel is important to have an understanding of. However, if there are any other questions that you may have, feel free to contact us at: contact@theursolution.com or give us a call at 888-503-5171

Here are the facts:

  • Utilization review is a health insurance company’s opportunity to review a request for behavioral health treatment. The purpose of the review is to confirm that the plan provides coverage for services. It also helps to determine if the recommended treatment is appropriate.

Utilization Management

  • The term “utilization management” is often used interchangeably with utilization review. Although they both involve the review of care based on medical necessity, utilization  management usually refers to requests for approval of future medical needs, while utilization review refers to reviews of past medical treatment. So utilization management is the process of preauthorization for medical service.

Utilization Review

  • The term utilization review refers to a retrospective review, which is the review of treatments of services that have already been administered. It is also the review of medical files in comparison with treatment guidelines. In the latter case, information retrieved during a utilization review can be used as part of a system that creates the insurance company’s guidelines for a given condition. When creating these documents, insurance companies not only use patient experiences but also review how physicians, labs and hospitals handle the care of their patients.

Concurrent Reviews

  • Much like precertification reviews, concurrent reviews are used for approval of medically necessary treatments or services. However, concurrent reviews happen during active management of a condition, be it inpatient or ongoing outpatient care. The focus of concurrent review is to ensure that the patient is getting the right care in a timely and cost-effective way.

Retrospective Review

  • The retrospective review involves the review of medical records after your medical treatment. The insurance company can use the results to approve or deny coverage you have already received, and the information can also be used in a review of the insurance company’s coverage guidelines and criteria for a particular condition. The other function of retrospective review is the approval of treatments that normally require precertification but were done without approval. This can happen if a patient is unresponsive and has not been able to obtain precertification.