Utilization Review

Utilization reviews are where care meets operations. Where clinical documentation and coding and billing lead to appropriate reimbursement for care delivery. And where patient severity of illness is properly reflected to impact quality performance.. 

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​The Eva SaaS allows for provides full service clinical review services, including ability for customer to respond to insurance denials with thorough and robust defense of clinical decision making. 

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The EvaluCare healthcare quality experts have led improvement initiatives to improve utilization review processes at hospitals and health systems that have led to millions in reimbursement benefits by decrease claim denials for customers.

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Sample list of areas of utilization review​​​​​

• Purpose and scope: Assess medical necessity, appropriateness, and efficiency of services, settings, and durations.

• Review timing/types: Prospective (precertification), concurrent (during care), and retrospective (after care).

• Evidence-based criteria: Use standardized guidelines (e.g., InterQual, MCG), payer policies, clinical practice guidelines, and coverage rules.

• Data sources: Admission notes, history and physical, progress notes, orders, vitals, labs, imaging, procedures, medications, care plans, and discharge summaries.

• Admission review: Verify medical necessity, correct level of care (inpatient, observation, outpatient), and expected intensity of services.

• Continued-stay review: Confirm ongoing medical necessity, progress toward goals, and appropriateness of length of stay and resources.

• Discharge planning and transitions: Evaluate readiness for discharge, post-acute needs, and safe, cost‑effective care transitions.

• Determinations and alternatives: Review alternative settings or services when appropriate.

• Payer communication review/adjudication: Manage prior auth, concurrent auth, peer-to-peer reviews, and clarify medical necessity with payers.

• Dispute response: Align determinations with payer benefits, preauthorization requirements, and provider contracts.

• Second-level review and appeals: Escalate complex cases to physician advisors; manage denials, appeals, and overturns.

• Governance integration: UR committee/planning reviews for RN reviewers, physician advisors, case management, etc.

• Metrics and reporting: Identify data for organizational tracking. (Track denial rates, avoidable days, length of stay vs. expected, readmissions, observation-to-inpatient shifts, turnaround times, and financial impact.)

• Compliance and standards: Meet CMS Conditions of Participation, Joint Commission/NCQA standards, HIPAA privacy, and state regulations.

• Continuous improvement: Analyze trends and root causes, educate clinicians, refine workflows, and update criteria/policies.

• Technology integration: Provide data inputs for existing UR software to standardize review processes, apply criteria, manage workflows.​​​​