What is the definition of Utilization Review?

A Utilization Review refers to the process of looking at medical insurance expenses, reviewing services and medications claimed to see whether these are reasonable and necessary for the treatment of the insured person.

To control costs involving medical claims, the insurance company routinely makes a review of its claims. It looks at the different services and benefits provided in a health insurance plan and looks at the charges, quantities and types of medical services that may account for the increase in the cost of claims.

During a utilization review, a medical practitioner such as a doctor or a nurse will go over the treatments provided to check for the existence of claims fraud, as well as to ensure that costs are managed properly.

• Insolvency
• Misstatement of Age or Sex Provision
• Modified Premium Policies
• Moral Hazard
• Comprehensive Coverage