Process and procedures implemented to administer the use of health care services in the hospital by evaluating quality of care and establishing appropriateness and medical necessity for services. It ensures maximum medical care resource use and helps reduce health care spending. Examples of UM are preadmission certifications, admission reviews, concurrent reviews, focused reviews, individual case management, discharge planning, retrospective reviews, provider profiling, and second surgical opinions.

Process, based on established criteria, of evaluating and controlling the medical necessity for services and providers’ use of medical care resources. Reviews are carried out by allied health personnel at predetermined times during the hospital stay to assess the need for the full facilities of an acute care hospital. In managed care systems such as an HMO, reviews are done to establish medical necessity and appropriateness or efficiency of health care services, thus curbing costs. UR is also monitored by both insurers and employers. Also called medical review, continued stay review, utilization , and management control .

Independent, nonprofit organization established in 1990 that promotes health care quality through its accreditation and certification programs. URAC offers a wide range of quality programs and services that keep pace with the rapid changes in the health care system and provide a symbol of excellence for organizations to validate their commitment to quality and accountability.

Registered nurse who evaluates medical cases for appropriateness of care and length of service and plans services required after discharge from a health facility.

1. In the insurance industry, state association that conducts utilization reviews for property and casualty insurers. 2. In health care, entity that has established one or more utilization review programs, which evaluates the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities.

Information that is aggregated by the capitated managed care entity (e.g., the number of primary care visits provided by the plan during the calendar year).