What is the focus of Utilization Review (4610)?

• A. Scheduling appointments
• B. Determining eligibility for benefits
• C. Review of medical necessity and appropriateness of care
• D. Processing death benefits

Answer: (C)

Utilization Review concentrates on whether the proposed medical services are medically necessary and appropriate for the patient’s condition. It involves evaluating the necessity, appropriateness, and efficiency of care against established guidelines or criteria, and it may include preauthorization, concurrent review, or reassessment of ongoing treatment. This process helps ensure that patients receive needed care without unnecessary or excessive interventions, while also supporting cost-effective decision-making. It isn’t about scheduling appointments, determining benefit eligibility, or handling death benefits, which are separate functions in the benefits system.