Definitions for "Utilization review"
An evaluation of the type and amount of services that a PASSPORT client is using and a determination of whether or not the services are justified.
A review of the appropriateness of medical services before, during and after a hospitalization or outpatient procedure. The objective is to improve the quality and decrease the cost of health care by systematically examining medical decisions and comparing them both to the standards established by the medical literature and the experience of the plan with similar patients.
Functions, including case management, performed by UNICARE, other payors, or an entity acting on behalf of UNICARE or an other payor that has been duly authorized and/or licensed, as applicable, as a utilization review agent to review and determine whether covered services provided, or to be provided, were or are medically necessary.