UR or management functions that prospectively, retrospectively, or concurrently review and approve, modify or delay based on medical necessity to cure or relieve treatment recommendations by physicians are known as

• A. Case management
• B. Utilization review
• C. Medical auditing
• D. Quality assurance

Answer: (B)

Utilization review is the process that prospectively, concurrently, or retrospectively evaluates the medical necessity and appropriateness of proposed, ongoing, or completed medical services. It reviews physician treatment recommendations and can approve, modify (such as substituting a different treatment or requiring additional information), or delay care based on established medical criteria, guidelines, or payer policies.

This focus on whether a treatment is necessary and appropriate is what sets utilization review apart from related functions. Case management centers on coordinating care and resources for complex patients, not primarily on deciding medical necessity. Medical auditing looks at whether records and billing meet standards and rules, while quality assurance concentrates on overall care quality processes rather than the real-time decision-making about specific treatments.