Review and analysis of health care programs to determine cost control methods. Involves reviewing claims for potential utilization problems.
All activities directly or primarily related to the provision of efficient, cost-effective and appropriate use of health care resources. These managed care techniques and tools are used to manage costs through case-by-case assessments of the clinical necessity for proposed medical services before, during and after treatment. UM techniques include precertification, case management, concurrent review, discharge planning, retrospective review, utilization review and others.
A process that measures use of available resources (including professional staff, facilities, and services) to determine medical necessity, cost effectiveness, and conformity to criteria for optimal use.
A system of procedures designed to ensure that the services provided to a specific client at a given time are cost-effective, appropriate, and least restrictive.
is a set of techniques used by or on behalf of purchasers of health care benefits to manage the cost of health care prior to its provision by influencing patient care decision-making through case-by-case assessments of the appropriateness of care based on accepted dental practices.
A methodology used by professional health personnel that assesses the medical indications, appropriateness and efficiency of care provided.
A review to determine whether covered services that have been provided or are proposed to be provided to you, whether undertaken prior to, concurrent with, or subsequent to the delivery of such services are medically necessary. See also: Coordinated Care.
The process used to determine the Medical Necessity, appropriateness, efficacy or efficiency of health care services. Techniques include inpatient admission review, continued inpatient stay review, discharge planning, post-care review and case management.
The process of evaluating and determining the coverage for and the appropriateness of medical care services, as well as providing any needed assistance to clinician or patient in cooperation with other parties, to ensure appropriate use of resources. Utilization Management includes prior authorization, concurrent review, retrospective review, discharge planning and case management.
(see also Case Management, Concurrent Review, Prior Authorization, Retrospective Review, Utilization Review): A set of techniques used by or on behalf of purchasers of health benefits to manage health care costs by influencing decisions about patient care made by providers, payers, and patients themselves.
The process of evaluating the medical necessity, appropriateness and efficiency of healthcare services against established guidelines and criteria.
The management of medical services or items by a physician, or other health care provider or facility, to insure quality of care, proper use of such services and items, and cost containment. The term would include all aspects of peer review, including pre-admission review, concurrent review and retrospective review, second opinions, physician and other staff training, bill auditing, and discharge planning.
A process that combines review and case management of medical services through the cooperative efforts of patients, providers, employers and insurers.
A process of integrating review and case management of services in a cooperative effort with members, groups and providers to optimize cost-effective patient care that doesn’t minimize quality.
The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria.
A form of case management and claims review where the insurance company analyzes a case to determine if the treatment given was appropriate or necessary.
This procedure or process utilizes a review coordinator to evaluate the necessity and appropriateness of various health care services.
Clinical and administrative mechanisms to regulate utilization, cost, appropriateness, and access to care
Managing the use of medical services to ensure that a patient receives necessary, appropriate, high-quality care in a cost-effective manner.
process of integrating clinical review and case management of services in a cooperative effort with other parties, including patients, employers, providers, and payers
Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. Typically it includes new activities or decisions based upon the analysis of a case.