Case Management

Case Management Q&A

Case Management Weekly, August 8, 2012

Q. What is utilization review?  

A. Utilization review is the process by which medical necessity is established using a systematic approach based on a set of criteria, standards of care, guidelines, or other methodologies in which a patient’s care is approved for reimbursement. 

The intent is to ensure that care delivered to patients is appropriate for time and setting and to control costs that will, in the end, provide sufficient monies to allow facilities to provide care to all constituents. 

This week’s Q&A is adapted from Prevent Denials and Win Appeals: The Hospital Case Manager's Guide to Revenue Integrity published by HCPro, Inc.

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