Utilization Review Licensing in Pennsylvania
Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Pennsylvania. For assistance with licensing, please contact us to learn about our software and managed license services.
Pennsylvania Utilization Review Entity Certification
| Type of Review: | Medical Utilization Review |
| Agency: | Pennsylvania Insurance Department - Bureau of Managed Care |
| Law: | 40 PA Stat. § 991.2151 |
Initial Registration
| Form: | |
| Agency Fee: | $1,000 for managed care plan utilization review, $2,000 for utilization review and external grievance appeal reviews. |
| Required Attachments: | See the application form for a detailed list of required attachments. |
Registration Renewal
| Form: | |
| Agency Fee: | $500 for managed care plan utilization review, $1,000 for utilization review and external grievance appeal reviews. |
| Due: | Triennially by the date of initial registration. |
| Notes: | Renewals must be submitted at least 60 days prior to the expiration of the certification period. |
Pennsylvania Resources
Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.
Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.
External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.
Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.
Prospective Review - Utilization review that occurs prior to treatment.
Retrospective Review - Utilization review that occurs after treatment and often after payment.
Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.
Utilization Review Agent (URA) - An entity that conducts utilization review.
Utilization Review Plan - A document of the procedures used during utilization review.
