Utilization review is how a health plan decides whether care it would otherwise cover is medically necessary. It is a judgment about clinical justification, not about the benefit. The service is in your policy; the question the reviewer asks is whether this patient needs this, at this level, now.
The names get used loosely, and the loose use hides the thing that matters. When the review happens decides what you can still do about it.
Prospective — before the care. This is what everyone means by prior authorization. The office submits, the plan approves or denies, nothing has happened yet. A denial here delays treatment and costs no money.
Concurrent — while the care is happening. An inpatient stay or a continuing course of treatment, reviewed as it runs. This is the timing that ends an admission or a treatment episode midstream, often with a day’s notice.
Retrospective — after the care is delivered. This is where a surprise denial on a bill comes from. The service happened, the clinician expected it to be covered, the review came afterwards and said no. Nothing can be rescheduled, and someone is holding a balance.
All three produce a decision you can appeal, and all three are worth getting in writing with the specific clinical criteria the reviewer applied. A peer-to-peer review — your prescriber on the phone with the plan’s reviewer — resolves a meaningful share of them before any appeal is filed.
In New York: there is a carve-out for addiction treatment, and it is narrow enough to be worth stating exactly rather than loosely.
At a facility certified by OASAS that participates in the plan’s network, an insurer may not require preauthorization for outpatient substance use disorder treatment. The same insurer may not conduct concurrent review during the first two weeks of continuous treatment, up to 14 visits. The condition attaches to the facility rather than to you: it must notify the plan within 48 hours that treatment has started, and tell the plan what the treatment plan is.
Read those conditions rather than the headline, because each one is load-bearing. Out of network, the carve-out does not apply. Not OASAS-certified, it does not apply. No notice inside 48 hours, it does not apply. And it holds review off for a defined opening rather than removing it — concurrent review resumes once that window closes.
Mental health sits beside this and is often argued in the same call, though it is a different kind of rule: outpatient mental health cost sharing at a state-licensed facility may not exceed the plan’s primary care copay. That is about price, not about permission. How parity works.
One boundary on all of it. These are state rules, so they reach state-regulated plans. A self-funded employer plan is federally regulated, and New York’s additions do not reach it.
Also called: UR, medical necessity review, prior authorization review. Full guide: How to appeal a denial in New York.
More in Glossary of health coverage and billing terms
- Out-of-pocket maximum — The out-of-pocket maximum caps your cost sharing for covered in-network care each plan year. What counts toward it, what never does, and the New York rules.
- Network (in-network and out-of-network) — The set of doctors and hospitals your plan has contracted with. Outside it, you pay much more.
- Formulary — A formulary is a plan's list of covered drugs, sorted into tiers that set your cost. What on-formulary means, how exceptions work, and New York's NYRx list.
This page explains how the system works. It is not medical advice. More.