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Definition of Utilization Review

The utilization review is "the evaluation of the medical necessity, appropriateness and efficiency of the use of health care services, procedures and facilities under the provisions of the applicable health benefits plan" after an accident.

The insurance company can use this evaluation to determine if the recommended treatment will be covered by your insurance plan. For instance, if your doctor recommends a particular treatment whether the insurance company will agree will presumably be based on the degree to which the recommendation meets the criteria established by previous reviews and practice standards. Standards have been established by state legislatures but vary state to state.

Generally, the criteria used to determine medical necessity must be precise and uniform. The patient must be notified of reviewed decisions in a timely manner. The staff doing the review must be qualified. There also must be an appeals process if the patient does not agree with the insurance company's decision.

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