The evaluation process used by healthcare organizations to assess the necessity, appropriateness, and efficiency of medical services and treatments.
The approval process required before certain medical services or treatments are provided, ensuring they meet the criteria set by the healthcare insurer or organization.
The determination that a specific healthcare service or treatment is essential for the diagnosis, prevention, or treatment of a medical condition, as determined by medical professionals.
The evaluation of medical services by qualified healthcare professionals, often peers of the treating physician, to ensure adherence to medical standards and guidelines.
The duration a patient spends in a healthcare facility, subject to review to ensure it aligns with the medical necessity and standards of care.
The excessive use of healthcare services or treatments beyond what is deemed medically necessary, leading to increased costs and potential negative impacts on patient outcomes.
The situation where necessary healthcare services are not used optimally, often due to barriers such as lack of access, awareness, or appropriate referral.
The rejection of coverage or payment for a specific healthcare service or treatment, often based on the findings of a utilization review.
The coordination and management of a patient’s healthcare services, often involving a designated case manager who ensures the provision of necessary and appropriate care.
The assessment of healthcare services and treatments in real-time as they are being provided to ensure ongoing medical necessity and appropriateness.