Utilization review
The process of evaluating the medical necessity and appropriateness of healthcare services.
Definitions (4)
Utilization review is the process conducted by private review agents or utilization review entities to assess the medical necessity, appropriateness, and efficiency of healthcare services, often prior to or during the provision of care, to determine insurance coverage.
The process by which health insurers, pharmacy benefit managers, and other entities determine coverage for healthcare services, subject to specific AI-related regulations under the Act.
The determination of requests for prior authorization under a health benefit plan according to the rules, health care service policies, and guidelines adopted by a health benefit plan provider, or requirements imposed by law, and applicable to a health benefit plan.
A system for reviewing the necessity, appropriateness, and efficiency of health care services, procedures, and facilities. This bill specifically regulates the use of AI within this process.