Which statement best describes the process of utilization review?

Which statement best describes the process of utilization review?

• A. A process to approve or delay treatment based on medical necessity
• B. A process to audit claims
• C. A process to determine insurance premiums
• D. A process to schedule appointments

Answer: (A)

Utilization review is the process of evaluating whether the proposed or ongoing medical services are medically necessary, appropriate, and efficient for the patient’s condition. In a self‑insured plan, this review can happen before care (prospectively), during care (concurrently), or after care (retrospective), and based on established clinical criteria it may approve, modify, or delay treatment. This focus on medical necessity distinguishes utilization review from other activities like auditing claims (which checks billing accuracy), setting insurance premiums (underwriting), or simply scheduling appointments. So the best description is a process to approve or delay treatment based on medical necessity.

Utilization review is the process of evaluating whether the proposed or ongoing medical services are medically necessary, appropriate, and efficient for the patient’s condition. In a self‑insured plan, this review can happen before care (prospectively), during care (concurrently), or after care (retrospective), and based on established clinical criteria it may approve, modify, or delay treatment. This focus on medical necessity distinguishes utilization review from other activities like auditing claims (which checks billing accuracy), setting insurance premiums (underwriting), or simply scheduling appointments. So the best description is a process to approve or delay treatment based on medical necessity.