Commission for Case Manager Certification (CCMC) Practice Exam 2025 - Free Case Manager Certification Practice Questions and Study Guide

Utilization review is primarily focused on evaluating past services, examining whether the care provided met established criteria for appropriateness and necessity. This process typically involves reviewing medical records and treatment plans to assess whether the services rendered align with clinical guidelines and standards. This retrospective analysis is essential for ensuring that patients received the appropriate level of care for their conditions and helps identify any deviations from best practices.

In contrast, utilization management encompasses a broader scope, which includes prospective, concurrent, and retrospective evaluations of care. It aims to manage healthcare services proactively, ensuring that patients receive the right care at the right time while also considering overall costs and resource utilization. By focusing on past services, utilization review specifically highlights its role in assessing the appropriateness of care already provided.