Utilization Review Decision Manager

Faster, More Accurate Application of UR Decisions in Bill Review

For decades utilization review and bill review have operated in silos, leaving a gap between treatment decisions and bill processing. Utilization Review Decision Manager (URDM) bridges that gap by electronically applying UR decisions directly within the bill review platform, resulting in faster processing, reduced labor costs and improved accuracy.

17%

more savings through accurate automated UR denials

Eliminate the Disconnect Between UR and Bill Review

Manual processes, human error and rising costs burden workers’ compensation programs, slowing productivity and diverting resources from higher-value priorities. A major contributor is the long-standing separation of two key cost containment services: utilization review (UR) and bill review.

UR determines whether treatment is reasonable and necessary, while bill review applies jurisdictional rules and identifies opportunities to control medical spend. When these functions operate independently, applying UR decisions during bill processing becomes a manual task that introduces inefficiencies, delays and the risk of costly errors.

URDM eliminates this disconnect by electronically applying UR decisions directly within the SmartAdvisor bill review platform. It removes the need for claim handlers to manually match approvals and denials to medical bills, ensuring treatment decisions are consistently reflected in payment outcomes.

How URDM Works

URDM replaces the time-consuming manual comparison of UR decisions to billed services with automated logic built directly into the bill review workflow.

UR decisions are electronically integrated into SmartAdvisor
System logic compares billed services to UR determinations
Related procedures and codes are grouped for accurate matching
Bills are automatically approved when aligned with UR decisions
Services that do not match are flagged for exception handling

Exceptions can be automatically denied, routed to custom work queues for specialist review or processed according to your organization’s specific handling directives.

Six Ways URDM Improves Claims Processing

1

Automation eliminates hundreds of hours of manual tasks.

2

Faster bill processing reduces backlogs and boosts productivity.

3

All determinations follow nationally recognized or state-mandated guidelines.

4

Tailored UR handling directives align with your claim handling philosophies.

5

Reduces human error and supports better clinical and financial outcomes.

6

Prompt adjudication expedites payment.

CASE STUDY

How One Carrier Saved $2M by Automating Utilization Review Decisions

See how embedding UR decisions directly into the bill review platform prevented unauthorized payments, reduced manual work and strengthened provider adherence.

Read the Full Story