The Right Care at the Right Time

Simply put, UR is a way for employers and/or claims administrators to determine if an injured worker’s proposed, ongoing or previously provided medical service, treatment or prescription medication is medically necessary. This is accomplished by comparing the clinical facts of the case against specific evidence-based treatment guidelines or criteria.

Utilization Review is mandatory in some states and generally can be used in most other non-mandated jurisdictions when there is a medical necessity question associated with a proposed, ongoing or provided medical treatment or service.

The process of Utilization Review focuses on ensuring that only appropriate and medically necessary care is approved. When medical necessity is questionable, the case is referred to an appropriately licensed medical professional for review and final medical necessity determination. Identification of unnecessary medical treatments or services provides an opportunity for the claims examiner to verify that the medical course meets accepted treatment guideline criteria, promoting optimal injured worker recovery and earlier claim resolution.

No. A medical Peer Review typically involves a full medical record review with specific issues to be addressed ranging from compensability, extent of injury, future treatment, and/or return-to-work. Utilization Review is specific to the question of medical necessity only associated with a proposed, ongoing or provided medical service or treatment.