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Utilization Review
An insurer's evaluation of whether a healthcare service is medically necessary and appropriate.
Full Definition
Utilization review (UR) is the process by which health insurers evaluate the necessity, appropriateness, and efficiency of healthcare services. It can occur before care (prospective review / prior authorization), during care (concurrent review — common for hospital stays), or after care (retrospective review). Utilization review is managed by clinical staff using evidence-based guidelines. Negative determinations can be appealed through your insurer's internal process and, if needed, through an external review.
Real-World Example
You're admitted to the hospital. Your insurer's concurrent review team contacts the hospital daily to assess whether continued inpatient stay is medically necessary. On day 3, they approve continued stay; on day 5, they recommend step-down to outpatient care.
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