What Is a Utilization Review in Health Insurance?

Utilization review (UR) is the process insurance companies use to evaluate whether a medical treatment, service, or hospital stay is medically necessary and appropriate. Understanding UR can help you navigate and challenge denials.

Types of Utilization Review

  • Prospective review: Before treatment — prior authorization decisions
  • Concurrent review: During treatment — ongoing hospital stay approval
  • Retrospective review: After treatment — reviewing claims already submitted

Who Performs the Review?

Insurers use clinical staff (usually nurses) for initial review. If the nurse cannot approve, the case goes to a physician reviewer — often a doctor who may not specialize in the relevant field.

Why UR Leads to Denials

  • The reviewer may lack expertise in your specific condition
  • Clinical guidelines used may be outdated or overly restrictive
  • Reviewers may not have access to your full medical history
  • Financial incentives may influence decision-making

How to Challenge a UR Denial

  1. Request the clinical criteria used to deny your claim
  2. Ask for the reviewer's credentials and specialty
  3. Have your treating physician do a peer-to-peer review
  4. Submit additional medical records and clinical evidence
  5. Cite current medical literature supporting the treatment

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Frequently Asked Questions

Is the utilization reviewer always a doctor?

Not always. Initial reviews are often done by nurses. However, federal and most state laws require that a denial based on medical necessity must be reviewed by a physician. You can ask for the reviewer's credentials.

Can I see the criteria they used?

Yes. Under the ACA, insurers must provide the specific clinical criteria used to deny your claim. Request this in writing — it's essential for your appeal.

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