What Is Utilization Review and How Does It Affect You?

Utilization review is the process insurance companies use to evaluate whether medical services are appropriate, necessary, and efficient. It's the mechanism behind most denials.

Types of Utilization Review

Prospective Review (Before Treatment)

  • Prior authorization requests
  • Pre-certification requirements
  • Step therapy protocols

Concurrent Review (During Treatment)

  • Continued stay reviews for inpatient care
  • Ongoing therapy session approvals
  • Treatment plan reviews

Retrospective Review (After Treatment)

  • Post-service claim reviews
  • Medical necessity determinations after care delivered
  • Audit reviews

How UR Leads to Denials

Insurance companies use clinical criteria databases (InterQual, Milliman) to evaluate requests. If your clinical situation doesn't match the criteria algorithm, the request is denied — often without a physician reviewing key nuances.

Challenging UR Decisions

  1. Request the criteria — you have the right to know what standards were applied
  2. Ask if a physician reviewed — non-physician reviewers have limited authority
  3. Request peer-to-peer — your doctor can speak with the medical director
  4. Appeal with specific guideline references that counter the UR criteria
  5. File regulatory complaint if UR is being applied inappropriately

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Frequently Asked Questions

Who performs utilization review?

UR is performed by insurance company staff — often nurses initially, then medical directors for denials. Some insurers outsource UR to third-party companies. Federal law requires that only a physician can make a final denial decision for medical necessity.

Can I see the criteria used to deny my claim?

Yes, you have the right to request the specific clinical criteria applied to your case. If the insurer refuses, this can be grounds for a regulatory complaint.

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