Utilization Management

Utilization Management (UM), initially referred to as Utilization Review (UR), remains a well-recognized component of a cost management approach in the health care service delivery and payment arenas. UM processes include interventions that take place before, during, and after the clinical encounter. The type of UM that occurs before the clinical event is called prior authorization or "pre-auth." If UM occurs during clinical care for a patient admitted to a facility, then this type of UM is called a concurrent review. Finally, UM that is done after the clinical encounter has occurred is called the retrospective review or "retro-review." The determinations of any of the three types of UM can result in a denial of either the request or for the payment for the service or procedure. If the provider disagrees with the UM determination, they typically have the ability to file an appeal of that denial, which would then be processed according to the organization's policies and procedures. Typically, there are two broad types of denials, benefit, and medical necessity. Benefit denials focus on the coverage benefits to which the patient is entitled (e.g., fertility services may not be covered benefit so such a service may be denied because of a lack of coverage) and medical necessity denials focus on the need for a specific service or procedure (e.g., an MRI for minor head trauma with no signs on physical exam may be denied as not medically necessary). There are typically formal time-frames set out for appeals based on the urgency of the situation and potential risk for an adverse outcome to the patient if an appeal for denial is not considered in a timely manner. Source: Giardino AP, Wadhwa R. Utilization Management. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: [https://www.ncbi.nlm.nih.gov/books/NBK560806/](https://www.ncbi.nlm.nih.gov/books/NBK560806/)