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Utilization Management

How do payers manage the use of health care services?

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Prospective Review

Policy Definition: Prospective review is conducted at the onset of a service or treatment and is also referred to as precertification or prior authorization. This review is performed before care is rendered in order to eliminate or reduce unnecessary services. source


Retrospective Review

Policy Definition: Retrospective review is conducted after the service has been completed and assesses the appropriateness of the procedure, setting, and timing in accordance with specified criteria. Such reviews often relate to payment and may result in denial of a claim or recovery of an amount already paid. source


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