Health · Chapter 14 · Cost Containment
Utilization Review (Case Management)
Definition
A specialist (often an RN) inside the insurer reviews large claims and treatment alternatives. Three timings: prospective (pre-certification BEFORE admission) · concurrent (DURING the stay — monitors length, setting, discharge planning) · retrospective (look-back AFTER treatment to refine guidelines, not to deny claims).
In plain English
Before, during, after — the insurer keeps asking 'is this care necessary and cost-effective?'
Exam tip
⚠️ UR is about TREATMENT decisions. 'Inspecting accident-prone individuals' is risk management, NOT utilization review. 'Pretense/congruent review' are fake terms.
Easy to confuse with
These are what this term gets tested against — if you can't tell them apart cold, drill the contrast.
Related terms