What is Utilization Review Documentation?

Utilization review documentation consists of records evaluating the medical necessity, appropriateness, and efficiency of healthcare services to determine insurance coverage. This documentation includes clinical assessments, treatment plans, provider notes, and reviewer determinations used by insurance companies to approve or deny coverage for specific treatments, procedures, or hospital stays based on established criteria.

Why utilization review documentation matters

• Influences coverage decisions: Determines whether services are approved for payment
• Ensures appropriate care: Verifies treatments meet medical necessity standards
• Controls healthcare costs: Prevents unnecessary or excessive services

How Solace can help

A Solace advocate can help you understand utilization review requirements, ensure proper documentation is submitted for coverage decisions, and assist with appeals when services are denied. Advocates can also help coordinate between providers and reviewers to expedite approval processes.