Which utilization review occurs before care and often includes prior authorization?

Which utilization review occurs before care and often includes prior authorization?

• A. Concurrent Utilization Review
• B. Utilization Management (UM)
• C. Prospective Utilization Review
• D. Retrospective Utilization Review

Answer: (C)

Prospective utilization review is done before care. It evaluates the planned services and often requires prior authorization before any treatment is provided, ensuring the proposed care is medically necessary and covered by the patient’s plan. This pre-service review prevents unnecessary or non-covered services from being approved. In contrast, concurrent review happens during treatment to monitor ongoing need, and retrospective review looks back after care to assess utilization and outcomes. The question’s focus on pre-care timing and prior authorization points to prospective utilization review as the best fit.

Prospective utilization review is done before care. It evaluates the planned services and often requires prior authorization before any treatment is provided, ensuring the proposed care is medically necessary and covered by the patient’s plan. This pre-service review prevents unnecessary or non-covered services from being approved. In contrast, concurrent review happens during treatment to monitor ongoing need, and retrospective review looks back after care to assess utilization and outcomes. The question’s focus on pre-care timing and prior authorization points to prospective utilization review as the best fit.