A Medical Utilization Review System for Ambulatory Care Based on Automated Claims Data

This article describes the use of an automated claims data base in reviewing the quality and medical necessity of ambulatory care provided to beneficiaries. The primary advantage to this approach is economy, since the data elements used in the review process are routinely collected as part of the claims payment process. This paper addresses issues relevant to the selection of physicians for review, strategies for improving the review process, and results of reviews conducted to date.