Florida Health Insurance Definitions

Florida Health Insurance Terms:
"Utilization Review"

Define: "Utilization Review"

The assessment of treatment in accordance with guidelines and standards that are established and accepted by health care professionals using medical necessity criteria. The assessment occurs before and during the delivery of health care. Its purpose is to enhance the cost-effectiveness of health care through reviewing its appropriateness.

ALSO: Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient.

More Examples of Utilization Review

"Utilization review is the term used for monitoring appropriateness of hospitalization for patients in a hospital. Most patients are hospitalized while someone else pays the bill. That someone wants to be sure that the bill isn't excessive or inappropriate.

Utilization review can be performed either by the third-party payer or by a department of the hospital. Frequently, the hospital will contract with the payer to perform the utilization review on the payer's behalf. In all cases, the utilization review department is usually involved in transmitting information about the patient to the payer. The information usually comes from documentation in the medical record. "

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