What process do insurers use to determine if a specific service is necessary for a patient's health?

The process insurers utilize to evaluate whether a specific service is necessary for a patient's health is known as Utilization Review. This process assesses the necessity, appropriateness, and efficiency of the healthcare services provided to ensure that patients receive care that's in line with established guidelines and standards.

Utilization Review can take many forms, including pre-authorization, concurrent review, and retrospective review. During these assessments, insurers may evaluate the medical necessity of procedures, treatments, or medications requested by healthcare providers to confirm they align with the patient's condition and recommended clinical practice standards.

Medical Necessity Review, while closely related, is essentially a concept encapsulated within the broader framework of Utilization Review. It specifically focuses on determining if the proposed services are medically necessary based on established criteria. Thus, although the term Medical Necessity Review indicates a specific focus, it is not the overarching process used by insurers like Utilization Review is.

Other options like the Medical Review Board and Claims Adjustment Review serve different functions within the insurance process and do not primarily address the assessment of service necessity in the same manner. The Medical Review Board typically oversees broader medical policy issues or appeals, while Claims Adjustment Review relates to resolving disputes on the claims processing side rather than evaluating medical services for necessity.