An Alabama Utilization Review Entity is a health services organization, approved by the Alabama Department of Insurance, that is qualified to perform utilization reviews for health care services. These reviews are used to assess the medical necessity, appropriateness, effectiveness, and efficiency of health care services requested by providers. The review process includes evaluating evidence-based standards of care and the patient's clinical characteristics to determine the appropriateness of the service and the most cost-effective treatment option. The types of Utilization Review Entity services qualified to perform reviews in Alabama include: Preauthorization reviews; Concurrent reviews; Retrospective reviews; Medical necessity reviews; and Quality of care reviews. Preauthorization reviews are performed prior to the initiation of a service to ensure the proposed treatment is medically necessary and consistent with the patient’s diagnosis and treatment plan. Concurrent reviews are conducted while the patient is receiving services to ensure the appropriateness of the care and the most cost-effective treatment option. Retrospective reviews are conducted after care has been provided to assess the appropriateness, effectiveness, and efficiency of the care. Medical necessity reviews are performed to assess whether the medical care provided is medically necessary and appropriate for the patient’s condition. Quality of care reviews are conducted to evaluate the quality of care provided and to identify areas for improvement.
An Alabama Utilization Review Entity is a health services organization, approved by the Alabama Department of Insurance, that is qualified to perform utilization reviews for health care services. These reviews are used to assess the medical necessity, appropriateness, effectiveness, and efficiency of health care services requested by providers. The review process includes evaluating evidence-based standards of care and the patient's clinical characteristics to determine the appropriateness of the service and the most cost-effective treatment option. The types of Utilization Review Entity services qualified to perform reviews in Alabama include: Preauthorization reviews; Concurrent reviews; Retrospective reviews; Medical necessity reviews; and Quality of care reviews. Preauthorization reviews are performed prior to the initiation of a service to ensure the proposed treatment is medically necessary and consistent with the patient’s diagnosis and treatment plan. Concurrent reviews are conducted while the patient is receiving services to ensure the appropriateness of the care and the most cost-effective treatment option. Retrospective reviews are conducted after care has been provided to assess the appropriateness, effectiveness, and efficiency of the care. Medical necessity reviews are performed to assess whether the medical care provided is medically necessary and appropriate for the patient’s condition. Quality of care reviews are conducted to evaluate the quality of care provided and to identify areas for improvement.
