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.
A review process conducted by managed care organizations in which a practices' use of procedures, hospital admissions, and other indicators of efficiency is monitored. Both overutilization and underutilization are monitored.
A system designed to monitor the use of, or evaluate the medical appropriateness, efficacy or efficiency of health care services, procedures, providers or facilities. utilization review may include ambulatory review, case management, certification, concurrent review, discharge planning, prospective review, retrospective review or second opinions. NCGS 58-50-61(a)(17).
An evaluation of the necessity, appropriateness and efficacy of the use of medical or institutional services.
A cost-containment measure used by health care insurers, third-party administrators and others to evaluate the need for treatment and assess alternatives to expensive or complex procedures. Among the techniques used are preadmission certification, solicitation of second opinions and use of rehabilitation programs. Evaluation of the use of hospital services, including admission, length of stay, ancillary services and outpatient costs, using objective clinical criteria. The objective is to ensure that services are medically necessary and provided at the appropriate level of care.
The review of services delivered by a health care provider to evaluate the appropriateness, necessity, and quality of the prescribed services. The review can be performed on a prospective, concurrent, or retrospective basis.
UR is the process of reviewing medical services for necessity, appropriateness, and efficiency to ensure that a patient is not given care that exceeds medical need and thereby reduce the number of unnecessary or inappropriate health care services. It includes review of admissions, length of stay, discharge, and services ordered and provided and is conducted on a preadmission, concurrent, and retrospective basis.
Retrospective analysis of the patterns of service usage in order to determine means for optimizing the value of services provided (minimize cost and maximize effectiveness/appropriateness).
A utilization management method intended to reduce the occurrence of unnecessary or inappropriate hospitalizations of patients.
The monitoring of the necessity and efficiency of health-care services and procedures is called the utilization review.
A method of claims review whereby the insurance company analyzes a case, either prospectively, concurrently, or retrospectively to determine if the treatment given is necessary and appropriate. Skip alphabetic navigation to V
Evaluation of healthcare delivery, using objective medical criteria, to ensure that the services are medically necessary, provided in the most appropriate setting and is quality care. back to the top
A cost-control method used by some insurers and employers to identify and reduce inappropriate and unnecessary care.
Hospital staff who work with doctors to determine whether a patient can get care at a lower cost or as an outpatient.
The evaluation of the medical necessity, efficiency, and/or appropriateness of healthcare services and treatment plans.
An insurerâ€™s review of a doctorâ€™s treatment plan, including length of hospital stay, to determine necessity, appropriateness and cost efficiency.
The evaluation of the medical necessity, efficiency or appropriateness of health care services and treatment plans.
A set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedure or settings.
(UR): The process used by insurance companies to decide whether to authorize and pay for treatment recommended by your treating physician or another doctor.
Insurer's review to determine the appropriateness of a doctor's treatment. This review may be prospective (before the treatment occurs), concurrent (during the treatment), or retrospective (after the treatment is completed).
A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. No V Items
An evaluation of the medical necessity, appropriateness, and cost-effectiveness of health care services and treatment plans for patients, performed on a case-by-case basis by a clinical review team. See Medical necessary.
(see also Utilization Management): A process used by a third party to assess whether a recommended treatment is medically necessary and appropriate based on standards of practice, practice guidelines, and other protocols.
MS = An organized procedure carried out through committees to review admissions, duration of stay, professional services furnished, and to evaluate the medical necessity of those services and promote their most efficient use. AN = DF: UTIL REV UI = D014600
A formal review of healthcare services for appropriateness and medical necessity. UR may be conducted on a prospective, concurrent or retrospective basis.
The review of services delivered by a health care provider or supplier to determine whether those services were medically necessary.
The process a member can use if a plan denies a service and says it is not medically necessary.
A method by which employers and insurers oversee the suitability, necessity, and quality of health-care services for the purposes of controlling costs.
A formal review of utilization for appropriateness of health care services delivered to a member on a prospective, concurrent or retrospective basis.
The practice of an HMO or other plan keeping track of a doctor's services and performance -- including drug utilization, tests and referrals -- to prevent what they consider over-treatment. Some plans require doctors to seek advance permission for every procedure, from surgery to diagnostic tests.
The process in which a team of doctors and other professionals regularly review treatment given to a patient in order to determine whether the treatment is appropriate and necessary. For example, a utilization review committee could review a request for admission to a hospital and determine that the admission is either necessary or not and therefore, it is either covered or not covered by the insurance or Medicare. Medicare utilization review committee decisions can be appealed by a beneficiary.
A method used in managed care approaches in which an outside organization reviews clinical decisions in areas such as hospital admission, length of stay, and discharge, as well as choices regarding placement and treatment modality in order to improve the quality of care and reduce costs.
a claim review approach by which an insurer analyzes a case to determine if the recommended treatment is both necessary and appropriate.
A system to evaluate dental use patterns that helps to identify and prevent program abuse.
Process used in managed care to ensure that services received by their consumers are medically necessary, cost effective, and are within the plan's requirements for care. Generally, treatment must meet the plan's guideline for medically necessity in order to be covered by the plan.
Process of certifying medical necessity for hospitalizations and procedures. Typically handled by an outside vendor arranged by the producer.
A cost control mechanism by which the appropriateness, necessity, and quality of health care is monitored by both insurers and employers.
A program designed to help reduce unnecessary medical expenses (usually hospital stays) by using preliminary evaluations and patient discharge practices.
Programs designed to reduce unnecessary medical services, both inpatient and outpatient. Utilization reviews may be prospective, retrospective, concurrent, or in relation to discharge planning.
Evaluation of the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. In a hospital, this includes review or the appropriateness of admissions, services ordered and provided, length of a stay, and discharge practices, both on a concurrent and retrospective basis. Utilization review can be done by a peer review group or a public agency.
Utilization Review is the review of how certain medical services are requested and performed. The review typically involved pre-review, or pre-authorization; concurrent review, or inpatient evaluation of care and needs; and retrospective review, or the larger historical picture of how physicians, labs, or hospitals handle their patient populations.