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Maine.gov > PFR Home > Insurance Regulation > Consumer Information > All Brochures > Utilization Review Requests, Decisions, and Appeals
Utilization Review Requests, Decisions, and Appeals
Four performance areas are presented in this Interactive Guide. Select from the toolbar above to view each of the comparative charts. Below each chart is a description on how to read and understand the results.
Utilization Review (UR) is a program used in managed care plans that is designed to reduce unnecessary medical inpatient or outpatient services. An individual or organization, on behalf of an insurer, reviews the necessity, use, appropriateness, efficacy or efficiency of health care services, procedures, providers, or facilities.
An appeal on an unfavorable UR decision occurs when a consumer asks an insurer to reconsider its refusal to pay for a medical service that the insurer considers not medically necessary. Insurers are required to have medical professionals review the appeals that they receive. Some common UR issues involve whether a hospital admission is necessary based on the medical condition, how long a stay in the hospital should be, and medical procedures.
A reversed UR appeal takes place when the health insurer decides in favor of the consumer and reverses its initial decision that it would not cover a service or procedure. Reversal Rate is the percentage of insurer/HMO decisions that were made against consumers and then were reversed after an additional review. For example, a 50% reversal rate shows that in 5 out of 10 appeals, the insurer/HMO changed its initial decision in favor of the covered person.
Last Updated: August 22, 2012
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