Under DRG, what is the role of the Utilization Review department and case managers?

• A. They determine hospital admission eligibility
• B. They set hospital room rates
• C. They evaluate whether a diagnostic test is medically necessary
• D. They approve all payments automatically

Answer: (C)

In DRG environments, the Utilization Review team and case managers focus on ensuring that the care provided is medically necessary and appropriate for the patient’s diagnosis. They review requests for tests and procedures to verify they are justified and aligned with the patient’s treatment plan, as well as with the DRG payment rules. This helps control costs and prevent unnecessary or non-beneficial services.

So the most accurate role is evaluating whether a diagnostic test is medically necessary. They do not set room rates or automatically approve all payments, and while admission decisions can be part of their work, the specific, best-fit function described here is assessing medical necessity of tests.