The insurance company’s process for checking whether continued treatment meets medical necessity standards.
In the context of addiction treatment:
UR staff review records and talk to providers to decide if they’ll continue paying for a certain level of care.
What to know:
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Can result in early pressure to step down from residential or PHP.
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Strong documentation from clinicians (risk, symptoms, ASAM dimensions) is key.
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You can often appeal UR decisions if your team believes you still need that level of care.
Example:
On day 21 of residential treatment, an insurance utilization reviewer questions whether you still meet criteria; your clinician advocates for another week due to recent cravings and unresolved housing.