Utilization Review Licensing in California
Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in California. For assistance with licensing, please contact us to learn about our software and managed license services.
California Utilization Review License
There is no license for utilization review in California, however, employers are generally required to submit a utilization review program to the Division of Workers' Compensation.More information: California Department of Industrial Relations - Division of Workers' Compensation
Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.
Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.
External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.
Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.
Prospective Review - Utilization review that occurs prior to treatment.
Retrospective Review - Utilization review that occurs after treatment and often after payment.
Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.
Utilization Review Agent (URA) - An entity that conducts utilization review.
Utilization Review Plan - A document of the procedures used during utilization review.