Utilization Review Definitions

Utilization Review
The process of comparing requests for medical services (“utilization”) to guidelines or criteria that are deemed appropriate for such services, and making a recommendation based on that comparison.

Prospective Review
Those conducted prior to the delivery of the services requested. Prospective reviews may be for inpatient or outpatient services.

Concurrent Review
Those performed while the worker is still hospitalized and services are being provided. Concurrent review also occurs with additional physical medicine.

Retrospective Review
Those performed after the requested service or procedure has already occurred and the worker has been discharged. Retrospective reviews may be inpatient or outpatient

Reviews requested by the provider or claim manager after a denial recommendation. Re-review may be requested during the initial review discussion or after claim manager decision. Re-review is performed by a matched specialty physician.

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