What is UR (Utilization Review) in Managed Care?

What is UR (Utilization Review) in Managed Care? Utilization review (UR) is how insurance companies decide if a healthcare service should be approved. They check if the treatment is needed, if it’s done in the right setting, and if it follows accepted guidelines.

UR is common in managed care. This includes private insurance, Medicaid, and Medicare Advantage plans. Without UR, providers may not get paid.

At Mint Billing, we work with providers to handle every part of the UR process. We make sure they send the right paperwork, meet deadlines, and follow up with insurance payers. This helps reduce denials and delays.

Why Managed Care Uses UR

According to CMS guidelines, utilization review is a key part of ensuring care is necessary and reimbursable managed care plans use UR to:

• Lower healthcare costs
• Prevent unnecessary treatment
• Make sure services are safe and effective
• Avoid paying for care that isn’t covered

Every service that gets billed must meet medical necessity. That means the treatment must match what’s needed for the condition. Insurance companies use UR to decide that.

What UR Looks At

UR looks at:

• What service is being given
• Why the patient needs it
• Where it’s being done (inpatient, outpatient, home, etc.)
• Who is providing it
• How long the treatment lasts

If something doesn’t match the plan’s rules, the service may be denied.

Types of UR in Managed Care

There are three main types of utilization review:

1. Preauthorization (or Prior Authorization)

This happens before the care is given. The provider must get approval from the insurance company first.

It’s used for services like:

• Surgery
• Residential treatment
• Physical therapy
• High-cost prescriptions
• Imaging (CT scans, MRIs)

If you don’t get preauthorization when it’s required, the claim can be denied—even if the care was correct.

2. Concurrent Review

This happens during treatment. The payer checks to see if the care should continue.

It applies to:

• Inpatient stays
• Detox programs
• Residential mental health treatment
• Rehab

The insurance company may approve more days—or deny continued care.

3. Retrospective Review

This happens after treatment. The payer looks at what was done and whether it was necessary.

If they think the care didn’t meet their guidelines, they can ask for money back. This is called a post-payment denial.

Who Performs Utilization Review?

UR is handled by:

• Registered nurses (RNs)
• Doctors (Medical Directors)
• Managed care case managers
• Third-party UR companies

These reviewers compare your documents to medical guidelines. If anything is missing or doesn’t match, they may deny the service.

How the UR Process Works

Step 1: The provider submits a request

This includes:

• Diagnosis
• Treatment plan
• Clinical notes
• Past medical history
• Lab results or imaging

Step 2: The insurance company reviews it

They check:

• If the service is medically necessary
• If it follows their rules
• If it fits the patient’s benefits

Step 3: A decision is made

The provider gets an answer:

• Approved: You can move forward.
• Denied: You need to appeal or change the treatment plan.
• Need more info: You must send additional records.

Step 4: If denied, you can appeal

This involves:

• Writing a letter
• Sending more documents
• Asking for a peer-to-peer review

What Can Go Wrong

• The paperwork is incomplete.
• You miss the deadline.
• The payer doesn’t respond in time.
• The request is denied.
• The care is given without approval.
• The provider doesn’t follow up.

These problems cause delays, lost income, and more stress. That’s why Mint Billing handles the full process—from request to appeal.

How Mint Billing Helps with UR

We manage utilization review for behavioral health facilities providers in all care settings. Here’s what we do:

• Submit authorizations: We gather documents and send the request.
• Track responses: We watch for approvals, denials, or requests for more info.
• Follow up: We contact payers if they take too long.
• Appeals: We write and send appeal letters for denied services.
• Concurrent reviews: We send updates for inpatient care.
• Retrospective support: We respond to audits and post-payment reviews.
• Document audits: We check that your records meet payer standards.

Where We Help the Most

We help providers in:

• Behavioral health (detox, residential, PHP, IOP)
• Primary care and specialty clinics
• Rehab and physical therapy
• Labs and diagnostic services

In each case, UR rules are strict. We make sure nothing falls through the cracks.

Common Problems We Solve

Problem	Our Fix
Missing documents	We create a checklist for each service
Denials	Write custom appeals
Late responses	We contact payers directly
Staff overwhelmed	Handle the UR so they don’t have to
No time for tracking	We use tools that track every step

UR in Behavioral Health

Behavioral health services are reviewed closely. Many plans want daily updates or regular reviews.

We help providers:

• Write clear progress notes
• Track levels of care
• Send timely updates
• Appeal when stays are denied too early

We work with facilities offering detox, residential treatment, partial hospitalization (PHP), and intensive outpatient programs (IOP).

UR and Insurance Billing

UR connects to billing. If the service is denied, the claim won’t be paid.

That’s why UR should never be a separate process. We connect it directly to billing. This avoids surprises and keeps your revenue flowing.

What You Can Do to Make UR Easier

• Use a checklist
• Document clearly
• Submit early
• Track each request
• Follow up
• Ask for help when needed

We can provide tools and training for your team too.

FAQs

Find some of the most billing FAQ’s:

What is medical necessity?
It means the service is needed based on the patient’s condition. Insurance companies use this to decide what they’ll cover.

How fast do approvals come?
It depends. Some take 1–3 days. Others can take longer. We follow up so they don’t fall through.

Do we always need preauthorization?
Not always, but many services require it. If you’re not sure, we’ll check for you.

Can patients appeal?
Yes. Patients or providers can appeal a denial. We help you with that process.

Are you able to do UR in-house?
Yes, but it takes time and training. Many providers ask us to take it over so they can focus on care.

Next Steps

UR is part of every managed care plan. If you skip it, you may not get paid. If you do it wrong, it could delay care.

Mint Billing helps you handle UR from start to finish. We manage requests, track responses, and fight denials.

Want help with UR?

• Contact us to talk about your needs.
• Ask for our UR checklist—we’ll send it free.
• Schedule a quick demo of how we track authorizations and reduce denials.

Have questions about utilization review or billing services? Mint Billing is here to help. Call us at (877) 715-7919