Utilization review
Utilization review is the process an insurer uses to decide whether a level of care is medically necessary, through prior authorization before admission and concurrent reviews during treatment that set how many days or sessions it will pay for.
Also called UR, concurrent review
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- 1 source, linked
- 4 related terms
What it means
At admission, plans often require prior authorization for higher levels of care. HealthCare.gov defines preauthorization as a decision that a service is medically necessary and notes that it is not a promise the plan will cover the cost. During the stay, staff at the center present clinical updates to the insurer's reviewer, who authorizes more days or recommends a step down.
Reviews are argued in level-of-care criteria, such as the ASAM Criteria or an insurer's own guidelines, which is why clinical documentation matters as much as the care itself.
Why it matters for your website
Utilization review happens off the website, but it shapes what the website should promise. Do not advertise a fixed length of stay as if the insurer has no say; explain how length of stay is decided.
Clear insurance pages prevent surprises later. Say that a benefits check is an estimate and that authorization is reviewed during treatment.
Sources
The facts on this page about a law, a regulator, a clinical standard or a platform come from these sources. Each link opens the original in a new tab.
- HealthCare.govGlossary: Preauthorization (opens in a new tab)
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