Utilization review assesses treatment against evidence-based criteria, occurring prospectively before treatment, concurrently during care, or retrospectively after services are rendered.
Determinations may approve, modify, or deny authorization.
Alternative Names:
UR, Medical Necessity Review (Health)
Why it Matters?
Utilization review records are useful in litigation because they document contemporaneous professional assessment of whether treatment was necessary, made before any dispute arose. A denial finding a proposed surgery unsupported by the clinical criteria carries weight the same conclusion reached by a retained expert does not. These records are held by the payer rather than the provider and require a separate request.
Frequently Confused with
Related terms
Frequently asked questions
Why are utilization review records useful?
Who holds these records?
