Which statement best describes utilization review?

• A. A process to review and approve medical treatment for medical necessity
• B. A process to calendar appointments
• C. A process to deny all care
• D. A process to calculate premiums

Answer: (A)

Utilization review is the systematic evaluation of proposed or ongoing medical care to determine whether services are medically necessary and appropriate. The goal is to ensure treatments, tests, and procedures are evidence-based, necessary, and efficient, while avoiding unnecessary or duplicative care. UR can occur before care is provided (prospective), during care (concurrent), or after care is delivered (retrospective). Clinicians review patient information against established guidelines and payer policies to decide if a service should be approved, modified, or denied, with the aim of controlling costs and protecting patients. It is not simply about scheduling appointments, denying all care, or calculating premiums.