What this page covers
Utilization review decides whether care meets medical-necessity criteria, and it runs against a clock across inpatient and outpatient settings. The work is repetitive: pull the clinical record, check it against criteria, submit to the payer, and handle the back-and-forth. Flexbone supports the administrative side so the nurse reviewers spend time on judgment, not phones and portals.
Prospective, concurrent, and retrospective review
Utilization management runs at three points. Prospective review clears care before it happens, the prior authorization for an admission or procedure. Concurrent review happens during an inpatient stay, justifying continued stay and level of care against the clock so the payer keeps authorizing days. Retrospective review handles cases reviewed after care, often tied to a denial and appeal. Each involves the same loop of gathering documentation and working the payer, across both inpatient and outpatient settings.
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Medical necessity criteria: InterQual and MCG
Payers and providers evaluate medical necessity against standardized criteria sets, most commonly InterQual and MCG. The reviewer matches the clinical picture, diagnoses, severity, treatment, and response, to the applicable criteria, then submits. Flexbone assembles the clinical record the criteria call for and submits the authorization or concurrent-review request through the payer portal or phone, then tracks it. When a case does not clearly meet criteria and the payer wants to discuss it, that routes to the peer-to-peer appeals workflow.
How Flexbone runs utilization review
Flexbone runs the administrative loop of UM: gather the documentation, submit against criteria, hold the payer line, capture the decision and authorized days, and schedule the next concurrent-review touch. Inpatient continued-stay and outpatient authorization both run as tracked queues, with results written back so case managers and billers see current authorization status. Clinical judgment stays with your reviewers; Flexbone removes the phone and portal time. The work is scoped to your settings and payers.