Utilization Review definition: Copy, customize, and use instantly
Introduction
The term "Utilization Review" refers to the process of assessing the necessity, efficiency, and appropriateness of medical services, treatments, or procedures. It is essential for controlling healthcare costs, ensuring compliance with insurance policies, and maintaining quality care standards. Utilization review plays a crucial role in medical decision-making, helping insurers, healthcare providers, and regulatory bodies determine coverage eligibility and resource allocation. It can be conducted prospectively, concurrently, or retrospectively to evaluate patient care and cost-effectiveness.
Below are various examples of how "Utilization Review" can be defined in different contexts. Copy the one that fits your needs, customize it, and use it in your contract.
Definition of "Utilization Review" as a healthcare cost management process
This definition applies "Utilization Review" to controlling medical expenses.
"Utilization Review" means the process of evaluating the necessity, efficiency, and appropriateness of medical services to manage healthcare costs and ensure proper resource allocation.
Definition of "Utilization Review" as an insurance coverage assessment
This definition ties "Utilization Review" to determining insurance benefits.
"Utilization Review" refers to the examination of medical procedures and treatments to decide whether they qualify for insurance reimbursement based on policy terms.
Definition of "Utilization Review" as a hospital admission evaluation
This definition connects "Utilization Review" to patient admissions.
"Utilization Review" means the assessment of hospital admissions to determine medical necessity, length of stay, and compliance with healthcare guidelines.
Definition of "Utilization Review" as a clinical appropriateness check
This definition links "Utilization Review" to clinical decision-making.
"Utilization Review" refers to the evaluation of prescribed treatments, tests, and procedures to ensure they align with clinical best practices and medical necessity.
Definition of "Utilization Review" as a pre-authorization process
This definition applies "Utilization Review" to medical service approvals.
"Utilization Review" means the pre-approval assessment of medical treatments and services before they are performed to confirm coverage eligibility.
Definition of "Utilization Review" as a post-service claims review
This definition ties "Utilization Review" to retrospective analysis.
"Utilization Review" refers to the evaluation of medical services after they have been provided to determine compliance with coverage guidelines.
Definition of "Utilization Review" as a prescription drug evaluation
This definition connects "Utilization Review" to pharmacy benefit management.
"Utilization Review" means the review of prescribed medications to ensure they are necessary, cost-effective, and appropriate for the patient’s condition.
Definition of "Utilization Review" as an employer-sponsored healthcare oversight
This definition links "Utilization Review" to workplace health benefits.
"Utilization Review" refers to the process employers use to monitor and control healthcare expenses under company-sponsored insurance plans.
Definition of "Utilization Review" as a compliance measure for medical necessity
This definition applies "Utilization Review" to regulatory standards.
"Utilization Review" means the systematic assessment of medical treatments to ensure compliance with state and federal healthcare regulations.
Definition of "Utilization Review" as a cost-containment strategy
This definition ties "Utilization Review" to financial oversight in healthcare.
"Utilization Review" refers to the process of analyzing medical service utilization to prevent unnecessary costs and reduce excessive spending.
Definition of "Utilization Review" as a process for appeal resolution
This definition connects "Utilization Review" to insurance claim disputes.
"Utilization Review" means the evaluation of denied claims or treatment requests to resolve disputes and determine final coverage decisions.
Definition of "Utilization Review" as a peer-reviewed medical decision-making process
This definition links "Utilization Review" to physician assessments.
"Utilization Review" refers to an evaluation conducted by medical professionals to assess the necessity and appropriateness of healthcare services.
Definition of "Utilization Review" as a risk management tool
This definition applies "Utilization Review" to reducing liability.
"Utilization Review" means the assessment of treatment plans to minimize medical malpractice risks and ensure quality patient care.
Definition of "Utilization Review" as an efficiency evaluation for treatment protocols
This definition ties "Utilization Review" to medical treatment efficiency.
"Utilization Review" refers to analyzing treatment approaches to determine whether they achieve the best health outcomes with minimal resources.
Definition of "Utilization Review" as a resource allocation method
This definition connects "Utilization Review" to hospital and insurance resource management.
"Utilization Review" means assessing the use of medical services to ensure fair distribution of healthcare resources.
Definition of "Utilization Review" as an external review process
This definition links "Utilization Review" to third-party assessments.
"Utilization Review" refers to an evaluation performed by an independent review organization to assess treatment necessity and adherence to medical guidelines.
Definition of "Utilization Review" as a specialist referral evaluation
This definition applies "Utilization Review" to specialist consultations.
"Utilization Review" means the review process used to determine whether specialist referrals are necessary and covered under a patient’s insurance policy.
Definition of "Utilization Review" as a data-driven healthcare analysis
This definition ties "Utilization Review" to healthcare analytics.
"Utilization Review" refers to the examination of healthcare utilization trends to identify overuse, underuse, or misuse of medical services.
Definition of "Utilization Review" as a long-term care assessment
This definition connects "Utilization Review" to senior and disability care.
"Utilization Review" means reviewing patient eligibility and care plans for long-term healthcare services, including nursing home stays and home health care.
Definition of "Utilization Review" as an emergency service validation process
This definition links "Utilization Review" to urgent care coverage.
"Utilization Review" refers to verifying whether emergency medical services meet criteria for coverage under insurance policies.
Definition of "Utilization Review" as a diagnostic test assessment
This definition applies "Utilization Review" to laboratory and imaging services.
"Utilization Review" means evaluating the necessity and appropriateness of diagnostic tests such as MRIs, CT scans, and blood work.
Definition of "Utilization Review" as a healthcare assessment process
This definition ties "Utilization Review" to evaluating medical necessity and resource allocation.
"Utilization Review" means the systematic evaluation of medical treatments and services to determine their necessity, efficiency, and compliance with established guidelines.
Definition of "Utilization Review" as an insurance approval mechanism
This definition connects "Utilization Review" to insurance coverage determinations.
"Utilization Review" refers to the process conducted by insurers or third-party administrators to assess the medical necessity and cost-effectiveness of proposed treatments before authorization.
Definition of "Utilization Review" as a cost-control strategy
This definition links "Utilization Review" to controlling healthcare expenditures.
"Utilization Review" means the structured review of medical services and procedures to optimize healthcare spending and ensure appropriate resource utilization.
Definition of "Utilization Review" as a regulatory compliance tool
This definition applies "Utilization Review" to meeting legal and policy requirements.
"Utilization Review" refers to the evaluation process used by healthcare providers and insurers to ensure compliance with regulatory standards and coverage policies.
Definition of "Utilization Review" as a retrospective evaluation
This definition ties "Utilization Review" to post-treatment assessments.
"Utilization Review" means the analysis of past medical treatments to determine their appropriateness, effectiveness, and adherence to coverage guidelines.
Definition of "Utilization Review" as a concurrent patient care review
This definition connects "Utilization Review" to real-time monitoring of ongoing medical care.
"Utilization Review" refers to the real-time assessment of ongoing treatments and services to ensure they align with medical necessity and insurance coverage.
Definition of "Utilization Review" as a prospective decision-making tool
This definition links "Utilization Review" to preemptive medical evaluations.
"Utilization Review" means the pre-authorization process used to evaluate the necessity and appropriateness of medical procedures before they are performed.
Definition of "Utilization Review" as a managed care function
This definition applies "Utilization Review" to managed healthcare systems.
"Utilization Review" refers to the review process within managed care organizations aimed at ensuring patients receive medically appropriate and cost-effective treatments.
Definition of "Utilization Review" as a claims adjudication process
This definition connects "Utilization Review" to insurance claim processing.
"Utilization Review" refers to the structured examination of medical claims to determine their validity, necessity, and eligibility for reimbursement.
This article contains general legal information and does not contain legal advice. Cobrief is not a law firm or a substitute for an attorney or law firm. The law is complex and changes often. For legal advice, please ask a lawyer.