What Is the Basic Criteria for a Utilization Review?


Quick Answer

The criteria for a utilization review is the source material utilized by a health-insurance company to determine if a claim qualifies for payment based on medical necessity, explains Arise Health Plan. Criteria include treatment guides, managed care guides, DSM-V criteria, medical directories and medical practice guides. Specific examples of criteria used by Arise Health Plan includes the APTA Guide to Physical Therapy Practice, Medical Policy Committee Decisions and the Hayes Medical Technology Directory.

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Full Answer

Insurance companies such as Arise employ specific bureaucratic processes for the approval of utilization review criteria, explains Arise Health Plan. The company's medical policy committee reviews potential criteria and makes recommendations to the quality assurance committee, which makes the decision on approval of criteria. Arise Health Plan also seeks input from plan practitioners and reviews criteria on an annual basis. The plan also adjusts criteria according to changes in standards, monitors the utilization review process and ensures that the company applies criteria consistently.

Certain types of claims require utilization reviews, according to the Washington State Department of Labor & Industries. For the Washington State Department of Labor & Industries plan, these include all in-patient hospitalizations, some outpatient surgical procedures, spinal injections, advanced imaging studies such as an MRI of the brain, and physical medicine such as physical and occupational therapy.

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