What is utilization and review?

• A. Reviewing patients' clinical condition and providing decision support to the physician on bed status and billing, including observation, outpatient, and inpatient; with justification of medical necessity; Additional certification required for admissions longer than 20 days.
• B. Handling discharge planning and social work referrals.
• C. Monitoring nursing staff compliance with charting standards.
• D. Approving medication formularies.

Answer: (A)

Utilization and review focuses on making sure patient care uses the right resources at the right level of care. It involves assessing the patient’s clinical condition and advising the physician on bed status and the appropriate setting—whether observation, outpatient, or inpatient—to match medical need and coverage requirements. A key part is documenting medical necessity and obtaining any required certifications to justify continued care, such as for admissions longer than a threshold like 20 days. This function helps prevent both underuse and overuse of services while ensuring payer requirements are met.

Other options describe different healthcare processes not central to utilization management: discharge planning and social work referrals are about arranging post-hospital care; monitoring nursing charting is quality/compliance work; approving medication formularies relates to pharmacology and formulary control.