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Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its medical appropriateness before it is provided, by using evidence-based criteria or guidelines.
A 2004 analysis of cases in California found that 33% of the time, the insurer's initial denial was overturned. [1] In the United States, independent medical reviewers may be selected by a regulatory body or by an insurance company, depending on the type of insurance and laws involved. In particular, self-funded plans have ERISA preemption. [2]
Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. [ 1 ] [ 2 ] A discipline-specific process may be referenced accordingly (e.g., physician peer review , nursing peer review ).
California insurers will be required to sell coverage in wildfire-prone regions that have seen an insurer exodus in recent years, state Insurance Commissioner Ricardo Lara announced Monday. Under ...
There are some issues addressed by this review: drug abuse clinically, alteration of drug dosage, drug–drug interaction, and drug-disease interaction. [1] Measure and record the blood pressure for next therapy. This review seems the best review over all three reviews because it is the closest option of the ideal. [11]
CVS Health's Caremark, Cigna's Express Scripts and UnitedHealth Group's Optum control the majority of the U.S. pharmacy benefit market, with their parent companies also operating health insurance ...
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