Health Care Utilization Review Forms for King
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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.
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.
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.
Utilization review is a method used to match the patient's clinical picture and care interventions to evidence-based criteria such as MCG care guidelines. This criteria helps to guide the utilization review nurse in determining the appropriate care setting for all levels of services across the arc of patient 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.