Utilization Review (UR) is a process implemented by hospitals, insurance companies, and other types of managed care plans. Included in the utilization review process, is the use of “explicit” criteria to determine the medical necessity of the treatment or the health care service appropriate for such a service. This is critical in order to assure a health service meets these stringent and generally accepted requirements and is likely to be covered by insurance reimbursement.

Physical status is evaluated against the criteria and a determination made as to whether or not a patient requires care at a particular level of service, i.e. hospital, in-patient rehabilitation, etc. The criteria used are usually developed by physicians, a review of current evidence and national guidelines published by specialty organizations.

There are levels in the utilization review process. The first level is the initial screening and review of health status and requested service by a licensed healthcare professional, usually a registered nurse or license social worker (outpatient therapy).  If there is any question regarding the need for services, the review is passed on to a physician, who holds active state licensure. That physician will review all available information, i.e. progress notes, admission history, lab data, x-rays, etc., and assess the appropriateness of the care.  If the physician determines that the care needs do not require the health services being received, he or she will sometimes discuss the care with the attending physician and determine an agreed upon treatment plan.  In some cases, there is not agreement between the attending physician and the reviewing physician and a “non-certification” notice is recommended.  With the non-certification notice, instruction is provided as to the opportunity for continued dialogue with your attending physician or how you can appeal the non-certification recommendation.

If the patient or the attending physician disagrees with the non-certification recommendation, there is a right to appeal, either telephonically or by letter to the insurance company making the recommendation.  An appeal can be “expedited”, requested immediately, or requested within a specific time period from the time of the notification.  On appeal, a specialty physician who is board-certified in the same area of practice as the attending physician will review all information, and make a recommendation to uphold or overturn the original recommendation.  In the event the appeal is not overturned, either on an expedited review or later, and the patient is still not satisfied, there may be additional appeal rights, depending on the state.

A nurse in utilization review assesses information, provides clinical information to others involved as needed and refers cases for review to physician peers in the event of any questions regarding medical necessity.