Prospective Review is a utilization review conducted before the requested medical service is delivered. Which statement best describes Prospective Review?

Prospective Review is a utilization review conducted before the requested medical service is delivered. Which statement best describes Prospective Review?

• A. It is a utilization review conducted after the requested service is delivered.
• B. It is a utilization review conducted during treatment.
• C. It is a utilization review conducted at the time of claim after service.
• D. It is a utilization review conducted before treatment starts and may include a review for a different body part.

Answer: (D)

Prospective review happens before any service is provided. It’s the preauthorization step where the reviewer checks whether the requested treatment is medically necessary and appropriate for coverage before you get the service. Sometimes, the review may also consider related or alternative body parts to determine the best, most appropriate option before treatment begins. This pre-service focus distinguishes it from concurrent reviews (which occur during treatment) or retrospective reviews (which occur after the service is completed). So the statement that best describes Prospective Review is that it is conducted before treatment starts and may include a review for a different body part.

Prospective review happens before any service is provided. It’s the preauthorization step where the reviewer checks whether the requested treatment is medically necessary and appropriate for coverage before you get the service. Sometimes, the review may also consider related or alternative body parts to determine the best, most appropriate option before treatment begins. This pre-service focus distinguishes it from concurrent reviews (which occur during treatment) or retrospective reviews (which occur after the service is completed). So the statement that best describes Prospective Review is that it is conducted before treatment starts and may include a review for a different body part.