What is the defined process of utilization review?

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Utilization review is fundamentally about assessing the necessity, appropriateness, and efficiency of healthcare services provided to patients. This process involves evaluating whether the services given are suitable for the patient's specific medical condition and whether they meet the established guidelines for care. It aims to ensure that patients receive care that is not only effective but also cost-efficient, thereby optimizing healthcare resources.

By focusing on the appropriateness of care provided, utilization review helps to maintain a balance between the quality of healthcare delivery and the costs associated with it. This is crucial in health management, as it aids in preventing over-utilization or under-utilization of services that could lead to poor health outcomes or unnecessary expenses.

Other processes mentioned, such as comparing different healthcare providers or evaluating healthcare technology, do not capture the essence of utilization review, which is centered specifically on the appropriateness and necessity of the services rendered to patients. The procedure for filing healthcare claims, while related to the broader healthcare system, does not relate directly to the clinical evaluation aspect of utilization review.

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