utilization review

n.
A process for monitoring the use and delivery of services, especially one used by a managed care provider to control health care costs.

Integral part of Managed Care health plans designed to control and limit medical expenses. This review includes: (1) requirement of certification for admission to a health care facility; (2) continuous analysis of the reasons for the patient to remain in the health care facility; (3) projected date for release of the patient; and (4) cost-effective ways of handling patients with catastrophic illnesses. See also Health Maintenance Organization (HMO); Preferred Provider Organization (Ppo).

n
UR

1. analysis of the necessity, appropriateness, and efficiency of medical and dental services, procedures, facilities, and practitioners. In a hospital, this includes review of the appropriateness of admissions, services ordered and provided, and length of stay and discharge practices, on concurrent and retrospective bases. 2. a statistically based system that examines the distribution of treatment procedures based on claims information and, to be reasonably reliable, the application of such claims. Analyses of specific dentists should include data on type of practice, dentists’ experience, socioeconomic characteristics, and geographic location.