In a managed health care plan, the process in which the utilization review organization reviews the necessity and quality of the medical care an insured received in a hospital following the hospitalization. See also managed health care plan and utilization review (UR).
After-treatment monitoring of utilization patterns against objective medical norms to detect inappropriate care (too little or too much) or excess cost. This is a component of utilization management.
A component of a utilization review program that provides an insurer with periodic reports on physicians' practice patterns and hospitals' average lengths-of-stay.----------[ Back
A review done after services are completed (usually as part of a claim or appeal), that ensures that the care given was medically necessary.
review by a health plan, after a specific drug has been dispensed or administered, that the drug was medically necessary, thus providing a promise of reimbursement It is also used to examine patterns of prescribing and billing by individual providers.
Review of services and supplies already provided to a patient to determine whether they were medically necessary or appropriate. NCGS 58-50-61(a)(17)(g).
The process where emergency room and urgent care center claims and their supporting documentation are reviewed by the clinical department to determine the health planâ€(tm)s liability for payment. Also known as post-service review.
A follow-up analysis that ensures medical care services were necessary and appropriate in order to detect and reduce the incidence of fraud and unnecessary services.
A utilization review that occurs after treatment is completed by the clinical team of the health plan in order to authorize payment and to confirm that it was medically necessary and that the course of care was appropriate.
(see also Concurrent Review): A form of utilization review conducted after services are provided to determine if the services met the requirements of the payer to justify reimbursement.
a method of determining medical necessity and/or appropriate billing practice for services that have already been rendered.
The evaluation of medical necessity and appropriate billing for services that have already been rendered.
The review and negotiation of a claimant's catastrophic hospital charges after discharge from facility. This is the least desirable form of negotiation as the patient has left the facility and the bill may have already been paid.