Utilization review assesses requested treatment against evidence-based guidelines to determine medical necessity. Determinations may approve, modify, or deny the request, and denials typically trigger an appeal or independent review process.
Many states mandate specific treatment guidelines that reviewers must apply.
Alternative Names:
UR, Medical Necessity Review
Why it Matters?
Utilization review is the primary control on medical cost in comp claims, and its effectiveness depends on procedural compliance. Determinations issued outside statutory timeframes are frequently deemed approved regardless of medical merit, which converts an administrative lapse into an authorized surgery. Carriers and TPAs treat UR timelines as hard deadlines for that reason.
Frequently Confused with
Related terms
Frequently asked questions
What happens if a UR decision is late?
Can a UR denial be appealed?
