Case Management

Case Management Q&A

Case Management Weekly, October 31, 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 basis for utilization review is to ensure that care delivered to patients is appropriate for time and setting and to control cost that will provided sufficient monies to allow for care to be provided to all constituents.  

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

Most Popular