Utilization review is a process used by managed care plans. This is done to determine whether or not a patient is approved for medical care that has been recommended by a doctor, or that the patient themselves has requested. The focus of the review is on the medical necessity of the treatment.
When a utilization review is performed, the managed care plan provider seeks to determine whether or not the treatment is required to either prevent, diagnose, correct or cure certain medical conditions. These conditions must cause the patient suffering, interfere with his ability to function normally, threaten a significant disability or endanger his life. The process also attempts to determine if the condition could result in an illness without the recommended treatment.
A managed care plan can conduct a utilization review once a patient or his doctor have requested a certain type of treatment. The patient also has the ability to ask for a utilization review if he is not in agreement with the decision regarding medical necessity. A review can also be requested in the event a patient wants to undergo experimental treatment that is not widely used. A patient can also request a utilization review if the plan refuses payment for treatment, such as cancer treatment, prescriptions or hospital stays.