What Utilization Review Aims To Do
Utilization review, or UR, checks whether a service is medically necessary, delivered at the right level of care, and supported by solid documentation. The goal is clean decisions that match coverage rules and protect patients from delays or unnecessary stays. In hospitals, UR sits beside case management and discharge planning; in health plans, it sits inside utilization management teams that handle prior authorization and concurrent review. Federal rules expect a written UR plan, a committee with physician involvement, and timely notices. See the CMS hospital Utilization Review requirement for the baseline, and use NCQA Utilization Management standards if you operate a plan or delegated UM program.
A good UR program blends objective criteria with fair clinical judgment. Start with a common set like InterQual or MCG, then add your local policies, payer rules, and service line nuances. Build a short playbook that everyone can follow on day one: when to review, what to collect, who can approve, when to escalate, and how to write notices. The map below keeps the flow tight from intake to decision.
| Step | What You Do | Who & When |
|---|---|---|
| Intake & triage | Confirm benefit, coverage, and request type; open case; set due dates. | UM nurse at receipt (same day). |
| Criteria selection | Choose InterQual/MCG path; flag level of care; capture red flags. | UM nurse within hours. |
| Evidence capture | Gather H&P, orders, labs, imaging, notes; add payer forms. | Intake staff or UM nurse on day 0. |
| Clinical review | Match facts to criteria; add clinical rationale; propose decision. | UM nurse; auto timers active. |
| Physician review | Send cases that miss criteria or need peer judgment. | Physician advisor within 24 hours. |
| Decision & notice | Approve, pend, or deny; send UM letter; log appeal rights. | UM nurse same day. |
| Care coordination | Align with attending; update discharge plan; close loop. | Case manager and UR lead daily. |
Doing Utilization Review In Healthcare: Stepwise Flow
Pick Criteria And Set Triggers
Pick a single criteria set for consistency across reviewers. InterQual and MCG are the common options, and payers often name one in contracts. Map triggers that launch a review: inpatient order, extended recovery, high-cost drug, implant, observation past 24 hours, or readmission within thirty days. Create a one-page matrix that pairs each trigger with the review type and turnaround time. Add payer specific exceptions so staff never guess. Keep a standing list of services that never need review under local policy, like low-risk outpatient imaging with no sedation. Fewer branches means fewer mistakes and faster decisions.
Collect The Right Data Fast
Design a standard intake that captures the facts payers and criteria expect. Use structured fields for chief complaint, working diagnosis with codes, vitals, key labs, imaging summary, procedures, orders, and start times for therapies. Pull the attending’s impression and the risk factors that drive severity. Add social needs that change setting, like home oxygen or caregiver limits. Attach required forms up front so reviewers do not chase paperwork later. Name files with a fixed pattern, such as member ID, date, and request type, so everything sorts cleanly inside your system.
Make A Decision And Document
Translate the chart into short, criteria-based notes that any auditor can read. Quote the criteria point, then cite the data that meets it, line by line. If the case misses, explain the clinical risk or intensity that warrants approval and send to the physician advisor. Use clear verbs: meets, fails, pends, approves, denies. State level of care, start date, and next review date. Store the rationale in a field that feeds letters so wording stays consistent. Tight notes save minutes now and hours during appeals.
Coordinate With The Attending
UR only works when the bedside plan and the payer plan match. Share level-of-care status with the attending and the charge nurse, and ask for missing elements that change the picture, like failed oral meds or need for telemetry. When criteria do not fit, set up a quick conversation with the physician advisor before the day slips. A five-minute huddle beats a denial next week. Keep a simple script so calls stay calm and focused on the clinical facts.
Notify Members And Track Clocks
Every decision runs on a clock. Track receipt time, review start, review finish, decision, and notice delivery. Use letter templates that carry the rationale, the reviewer’s name, the criteria source, and the exact appeal steps. Send notices through the member’s preferred channel and log proof of delivery. Build timers that warn staff when a case nears a deadline. Late decisions damage trust and can trigger penalties or auto approvals under contracts.
Healthcare Utilization Review Process: What To Prepare
Strong preparation keeps daily work smooth. Align policies with federal rules and payer contracts, and keep them short enough that staff use them. Maintain a current roster of reviewers, alternate reviewers, and physician advisors with contact routes for nights and weekends. Keep a library of criteria licenses and payer manuals inside your knowledge base so reviewers never hunt across shared drives. House version control in one spot, and date the top line on each policy.
Build A Lean UR Plan
Write a compact plan that names scope, settings, review types, criteria sources, decision rights, peer review steps, and committee structure. Name how cases are selected for second-level review, how conflicts are handled, and how peer-to-peer calls run. Set a schedule for UR committee meetings and define the reports that go there each month. Include a short section on member rights and communication standards that mirrors payer and state rules.
Define Roles And Escalation
Spell out who can render a decision, who can pend, who can deny, and who must review a case that misses criteria. Tie escalation to time and risk. A case with a fast discharge plan can wait for the next meeting; a case that blocks a bed or uses high-cost implants needs a physician decision inside the same day. Publish a phone tree and a text template so staff reach the right person fast.
Create Clear Notices And Letters
Notices are where trust lives. Use plain language and a layout that non-clinicians can follow. Name the service, the reason, the criteria set, the facts used, and the appeal path. Add the exact deadlines and the start of any continued stay review. Test letters with a small member panel and edit until people can retell the decision without extra help. Keep versions aligned with payer templates to reduce returns.
Set Up Technology And Data Feeds
Pick a platform that can auto-ingest clinical data from the EHR and send decisions back to the chart. Add real-time dashboards for open cases, timers, and pending peer reviews. Keep audit trails on by default. Build exports for denials, overturned decisions, and time stamps, so analytics never relies on manual logs. Connect to your prior authorization APIs where available, in line with the CMS prior authorization rule.
Prior Authorization Rules You Cannot Ignore
Electronic exchange is moving fast. Many payers subject to federal programs now publish prior authorization APIs and timelines for decisions under CMS-0057-F. Build your workflows to request status updates electronically, receive reason codes, and return needed data elements without extra phone calls. Use payer turnaround times in your timers. If a rule sets deadlines for urgent requests, your letters and dashboards should reflect that clock from the moment a request lands.
Appeals, Peer-To-Peer, And Denials Management
Treat every denial as a teachable event. Classify by service, payer, reason code, reviewer, and setting. Build a same-day review that checks whether criteria were applied correctly, whether the record had missing facts, and whether the letter matched the clinical story. Offer peer-to-peer with a script that opens with risk, response to treatment, and plan for safety. Send appeal packets with a clean index, the decision letter, the full rationale, and the key progress notes in order.
| Reason | Tell-Tale Signs | First Fix |
|---|---|---|
| Medical necessity not met | Criteria points missing in notes; vitals or failed treatment absent. | Add objective data; request attending add response to treatment and risk. |
| Wrong level of care | Observation billed but criteria show inpatient acuity, or reverse. | Reassess criteria; update order; document intensity and expected length. |
| Timing missed | Review beyond payer clock; notice late. | Tighten timers; add backup reviewer; send notices via multiple channels. |
| Insufficient documentation | H&P lacks impression; imaging summary missing; forms blank. | Use intake checklist; pre-load required fields; train on concise summaries. |
| Experimental or not covered | Service excluded under plan language. | Verify benefit early; offer covered alternative; route to medical director. |
| Duplicate request | Two cases open for same service. | Merge cases; close duplicates; adjust intake process. |
Quality, Equity, And Member Impact
UR touches real lives. Use timeliness and clarity as daily anchors. Track whether decisions arrive before discharge, whether letters match reading level targets, and whether translation is offered when needed. Watch for patterns that cause unequal denials across language, age, or zip code. Bring that view to your UR committee and invite frontline input. When a pattern appears, fix the process, not only the case. The best UR teams reduce avoidable days and keep members engaged with care.
Metrics, Dashboards, And Audits
Pick a lean set of measures and post them where teams can see progress. Core picks: turnaround time by request type, percentage of approvals at first level, overturn rate after peer review, denials by reason, late letters, avoidable days, observation to inpatient conversion rate, and discharge before decision. Trend by service and payer. Publish a simple scorecard for the UR committee and set one improvement target per quarter. Tie coaching to the metrics, not to blame.
Training And Scripts That Work
Give new reviewers short drills with real cases and timed decisions. Use side-by-side sessions with senior nurses and physician advisors. Record a few model calls that show how to frame risk and plan in sixty seconds. Share micro scripts for common moments: asking the attending for missing data, opening a peer-to-peer, explaining a pend, and clarifying appeal steps with a member. Short phrases carry better than long monologues.
Common Pitfalls You Can Avoid
- Waiting for the perfect EHR feed before starting automation; manual uploads with a tight naming rule work fine while APIs mature.
- Letting criteria citations drift; reviewers should always quote the exact point and date the version used.
- Mixing UM and case management updates in the same note; split them so auditors and payers can follow the trail.
- Delaying peer-to-peer until the deadline; early calls save beds, supplies, and patient time.
- Writing letters that mirror internal jargon; write for a ninth-grade reader and test with members.
- Skipping weekend coverage; Monday piles turn quick wins into denials.
Edge Cases And Smart Moves
Some requests need a different lens. Pediatric stays, maternity care, rehabilitation, transplant, hospice, and behavioral health often have extra rules or separate criteria. Keep quick sheets that list service specific triggers, minimal data sets, and any state rules. For inpatient only lists, keep the current code set inside your tool so reviewers can check status in seconds. When payers require site-of-service review for high-cost drugs or infusions, pre-populate the letter with the product name, dosing plan, and safe alternate sites. When a case spans midnight or crosses units, repeat the review only if new facts change the level of care. Avoid duplicate work that adds no value.
Peer review agreements keep fairness intact. Use paired lists of external reviewers by specialty for cases where internal advisors cannot serve. Set payment terms and response windows ahead of time. Share only the facts needed for a clean decision and strip names that could bias a reader. When the external opinion arrives, attach it to the rationale and move the case within the same day. Keep a log of external reviews so your committee can watch for volume spikes.
Next Steps That Stick
Start small, measure weekly, share.