Utilization Management Fundamentals for the CPHQ

Utilization Management (UM) ensures that healthcare services are medically necessary, appropriate, and efficient. The CPHQ exam tests your understanding of UM review types, criteria, and how UM connects to quality outcomes.

Types of UM Review

Pre-authorization (Prospective Review): Evaluation before services are provided. Determines whether a proposed treatment, procedure, or admission meets medical necessity criteria. Common for elective surgeries, advanced imaging, and specialty referrals.

Concurrent Review: Evaluation during the patient's hospitalization or course of treatment. Monitors whether continued stay is medically necessary, identifies patients ready for discharge, and coordinates discharge planning. Conducted by nurse reviewers with physician advisors.

Retrospective Review: Evaluation after services have been provided. Reviews medical records to determine if care was appropriate and medically necessary. Used for claims review, quality audits, and identifying patterns of over-utilization or under-utilization.

Clinical Decision Support Criteria

UM decisions are guided by evidence-based criteria sets. InterQual and Milliman Care Guidelines are the most widely used. These tools provide objective, standardized criteria for admission, continued stay, and level of care decisions. When a case does not meet criteria, it is referred to a physician advisor for review.

UM and Quality

UM supports quality by ensuring patients receive the right care, in the right setting, at the right time. Effective UM reduces unnecessary hospitalizations, shortens length of stay where appropriate, ensures timely discharge planning, and identifies patients who may need care coordination. UM data also supports quality improvement by identifying patterns in care delivery.