Which term describes a structured process for reviewing medical necessity and appropriateness?

The term that describes a structured process for reviewing medical necessity and appropriateness is utilization management. This process involves evaluating healthcare services to determine whether they are needed and whether they meet specific guidelines and standards for care. Utilization management aims to ensure that patients receive appropriate care while minimizing unnecessary services and costs to the healthcare system.

This process typically incorporates criteria such as clinical guidelines, patient medical history, and evidence-based practices. By assessing the necessity and appropriateness of healthcare services, utilization management helps improve patient outcomes and optimize resource utilization within healthcare facilities. This structured review process can include pre-authorization, concurrent review, and retrospective review of care.

Other options represent different concepts within healthcare management. Claims processing focuses on the administrative aspect of handling insurance claims and payments but does not involve a systematic review of medical necessity. Risk management involves identifying and mitigating risks within the healthcare setting to improve patient safety and organizational outcomes. Case management is centered on coordinating comprehensive care for patients, particularly those with complex medical needs, but it does not specifically refer to the evaluation of medical necessity and appropriateness as a structured process.