Utilization review and pre certification services Forms for Fairfax
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FAQ
A utilization review is a process in which a patient's care plan undergoes evaluation, typically for inpatient services on a case-by-case basis. The review determines the medical necessity of procedures and might make recommendations for alternative care or treatment.
Utilization review contains three types of assessments: prospective, concurrent, and retrospective.
There are three activities within the utilization review process: prospective, concurrent and retrospective. Prospective review includes the review of medical necessity for the performance of services or scheduled procedures before admission.
While utilization review identifies and addresses service metrics that lie outside the defined scope, while utilization management ensures healthcare systems continuously improve and deliver appropriate levels of care. Reducing the risk of cases that need review for inappropriate or unnecessary care.
Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called utilization review.
While utilization review identifies and addresses service metrics that lie outside the defined scope, while utilization management ensures healthcare systems continuously improve and deliver appropriate levels of care.