Medical Utilization Evaluation

The medical utilization evaluation is a process through which patients who are medically insured are able to get the required care from the necessary medical facilities. There are certain standards that have to be met. There will be a lot of reviewing and certification done before receiving the medical care. However, one must note that by gaining medical certification it does not guarantee treatment. The medical insurance does cover only certain benefits and these are only received if the patient meets the eligibility criteria.

The evaluation is a rigorous process and needs to be carefully done so that the patient receives the right treatment and does not cheat the medical facility or the insurance company. Likewise, the evaluation also helps the patient secure treatment fairly. These will include CAT scan, MRI, private home health car, nursing home care, hospice care services and more. The patient must inform the medical insurance company in advance for the evaluation to take place.

Sample Medical Utilization Evaluation

Patient Name: Chicly Barker

Age: 56 years

Gender: Female

Medical Requirement of the Patient:

  • The patient has been admitted in Cheshire Cancer Research Center on 5.6.2012
  • This admission has been done on an emergency basis
  • The patient is required to have advanced radiation therapy
  • The patient will be staying till the treatment is complete for two weeks.

Evaluation Request:

  • The patient’s daughter, Berkley Barker, requests MEDIVALUE Insurance Co. to look over the medical details and make the required payments for the stay-in and other medical requirements.
  • The patient coverage does not cover radiation therapy and will have to bear the expenses herself.

Evaluation Result:

  • All examinations have been made including the recent doctor’s report on the patient’s condition.
  • MEDIVALUE will pay for the 2 week stay as it meets the benefits of the insurance policy selected.


Category: Medical Evaluation

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