What's the Difference Between Utilization Review and Peer Review?

What you will find below:

• Overview of Utilization Review and Peer Review
• How the Two Processes Differ
• When to Use Each
• Why the Distinction Matters

Utilization review and peer review both help evaluate medical treatment in workers’ compensation claims, but they serve different purposes. Utilization review determines whether requested treatment meets applicable medical necessity criteria. Peer review provides a clinical opinion on specific medical questions.

Understanding the difference helps claims professionals identify the appropriate review for different situations.

What Is Utilization Review?

Utilization review (UR) evaluates whether medical treatment is medically necessary and appropriate based on established clinical criteria and medical evidence.

The review considers treatment recommendations alongside applicable medical guidelines and the injured worker’s clinical information.

Utilization review is typically conducted by qualified healthcare professionals, such as physicians or nurses, who evaluate treatment requests against applicable medical necessity criteria.

Depending on the circumstances and state requirements, utilization review may occur before treatment, during treatment, or after services have been provided.

For example, when a physician recommends additional physical therapy sessions, utilization review may assess whether continued treatment meets applicable medical necessity criteria.

What Is Peer Review?

Peer review involves a qualified healthcare professional evaluating medical information to address specific clinical questions.

A physician peer review may include an examination of medical records, treatment recommendations, and other clinical documentation. The reviewer uses medical expertise to provide an independent professional opinion.

Peer reviews are conducted by qualified healthcare professionals, often physicians with relevant clinical experience or expertise in the area being reviewed.

Unlike utilization review, which centers on medical necessity, peer review can address a broader range of clinical questions. These may include the extent of an injury, the clinical support for a diagnosis, or recommendations for future treatment.

For example, when a claim involves conflicting medical opinions, peer review may help clarify the medical evidence supporting each recommendation.

Utilization Review vs. Peer Review: What’s the Difference?

The main difference between utilization review and peer review is the purpose of the evaluation.

Utilization review:

• Focuses on medical necessity and treatment appropriateness.
• Applies established medical guidelines and review criteria.
• Supports treatment determinations.
• Follows a defined review process.

Peer review:

• Addresses specific clinical questions.
• Evaluates medical evidence using clinical expertise.
• Provides professional medical opinions and findings.
• Varies in scope based on the question being reviewed.

Both processes involve evaluating medical information, but the questions they answer are different.

When Are Utilization Review and Peer Review Used?

The appropriate review depends on the medical question, the circumstances of the claim, and applicable state requirements.

Utilization review is appropriate when a treatment recommendation needs to be evaluated against medical necessity criteria. Common examples include requests for diagnostic imaging, surgery, or additional physical therapy.

Peer review may be appropriate when a claim requires further clinical evaluation. This could include conflicting medical opinions, questions about the extent of an injury, or concerns about the clinical basis for a proposed treatment plan.

Requirements for medical reviews vary by jurisdiction. Claims professionals should consider applicable state rules when determining which process is appropriate.

Why the Distinction Matters

Both utilization review and peer review provide valuable clinical information for workers’ compensation claims. However, they are not interchangeable. Each serves a different purpose in evaluating medical treatment and addressing clinical questions.

Understanding when to use each process helps claims professionals direct medical questions to the appropriate review, support informed decisions, and maintain an effective medical management process.

Connect with our team to learn more about these services and their role in claims.

Sources:

• California Department of Industrial Relations. “Utilization Review Standards—Definitions.” California Code of Regulations, tit. 8, § 9792.6.1, amended effective 1 Apr. 2026. https://www.dir.ca.gov/t8/9792_6_1.html.
• Texas Department of Insurance. “Adopted Sections.” Texas Department of Insurance, https://www.tdi.texas.gov/rules/2005/1115a-059.html.
• URAC. “Workers’ Compensation Utilization Management Accreditation.” URAC, https://www.urac.org/accreditation-cert/workers-compensation-utilization-management-accreditation/.