Utilization Review determines if provided or proposed health care services were/are medically necessary. Does it apply to emergency services?

Utilization Review determines if provided or proposed health care services were/are medically necessary. Does it apply to emergency services?

• A. It determines if services were medically necessary and applies to emergency services.
• B. It determines only the adequacy of documentation for billing.
• C. It determines if services were medically necessary and does not apply to emergency services.
• D. It is the same as a preauthorization review.

Answer: (C)

Utilization Review focuses on whether care is medically necessary, guiding coverage decisions for services that are planned or proposed. For emergency situations, there isn’t time to obtain prior authorization, so this review isn’t used to preauthorize emergency services. In practice, UR is about confirming medical necessity for proposed or provided care, but it doesn’t apply to the preauthorization of emergency services. That’s why the best choice states that it determines medical necessity and does not apply to emergency services.

Utilization Review focuses on whether care is medically necessary, guiding coverage decisions for services that are planned or proposed. For emergency situations, there isn’t time to obtain prior authorization, so this review isn’t used to preauthorize emergency services. In practice, UR is about confirming medical necessity for proposed or provided care, but it doesn’t apply to the preauthorization of emergency services. That’s why the best choice states that it determines medical necessity and does not apply to emergency services.