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This online PDF text-based course introduces the concepts, language, and processes of Utilization Review (UR) for interprofessional providers acting as patient advocates, including physicians, nurses, medical office staff, professional patient advocates, and other individuals that want to expand their knowledge of UR and its role in managed health care.
Managed Care and the practice of UR of health care services are accepted methods for dealing with health care costs. Ongoing changes in the federal government's role in the health care system make it even more important to understand UR concepts, how UR affects patient access to care, and what to do when a requested health care service is denied (adverse determination). The Affordable Care Act created access to "external reviews", an additional level of review that allows review of denied health care by an independent review organization (IRO) that is unrelated to the insurance carrier. Therefore, knowledge of the UR process, various levels of review, and how to negotiate in this environment is a powerful asset to facilitate the patient's navigation through the complexities of the health care system. The appropriate use of the grievance and appeals process is an essential skill. It is in every patient advocate's best interest to become familiar with the principles of UR to utilize this knowledge to maximize patients' access to medically necessary care.
This course provides a detailed explanation of how advocacy professionals navigate the UR process to obtain the best outcomes for their clients. Learners will be well-prepared to play a needed role in assisting patients with understanding health care options and how to appropriately respond to denials of requested health care services. Denials of service can cause frustration and anger. However, by applying your skills to one issue at a time, you will help each patient understand the process and how to cope in ways that maximize health. These skills will be useful to anyone trying to work their way through the health care maze, whether your patients, family, or yourself.
At the conclusion of this activity, members of the interprofessional team should be able to better:
Define the spheres of influence, their roles, and interactions in the utilization review process
Recognize the various levels of review and how to advocate on a patient's behalf at each level
Identify common utilization review topics
Define the difference between an internal and external review, and determine when an appeal is appropriate
Recognize the reasons for denials and how to put together an appeal that addresses the identified deficiencies
Identify various sources of evidence-based medicine (EBM) and how to use EBM to support an appeal
Integrate clinical, health plan language, and medical reference material to create an appropriate appeal letter
Faculty includes:
Linda G. Sheff, MBA, CHCQM
About the Authors
Members of the Education Committee, Planners, and Faculty have no relevant financial relationships with ineligible companies to disclose.
ACCREDITATION & CREDIT
In support of improving patient care, the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physicians
ABQAURP designates this enduring material for a maximum of 4.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nurses
This activity is designated for 4.5 nursing contact hours.
The American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) is an approved provider with the Florida Board of Nursing to provide continuing education for nurses. ABQAURP designates this activity for 4.5 contact hours through the Florida Board of Nursing. Provider # 50-94.
This program is approved for Category 2 credit by the American Osteopathic Association.
This activity was planned by and for the healthcare team, and learners will receive 4.5 Interprofessional Continuing Education (IPCE) credits for learning and change.
This activity is valid from April 17, 2025 through April 16, 2028. (Previously valid March 8, 2022 through March 7, 2025. Reviewed March 2025.)
Pricing:
Diplomate Members $170.00
Professional Members $190.00
Non-Members $230.00
Managed Care and the practice of UR of health care services are accepted methods for dealing with health care costs. Ongoing changes in the federal government's role in the health care system make it even more important to understand UR concepts, how UR affects patient access to care, and what to do when a requested health care service is denied (adverse determination). The Affordable Care Act created access to "external reviews", an additional level of review that allows review of denied health care by an independent review organization (IRO) that is unrelated to the insurance carrier. Therefore, knowledge of the UR process, various levels of review, and how to negotiate in this environment is a powerful asset to facilitate the patient's navigation through the complexities of the health care system. The appropriate use of the grievance and appeals process is an essential skill. It is in every patient advocate's best interest to become familiar with the principles of UR to utilize this knowledge to maximize patients' access to medically necessary care.
This course provides a detailed explanation of how advocacy professionals navigate the UR process to obtain the best outcomes for their clients. Learners will be well-prepared to play a needed role in assisting patients with understanding health care options and how to appropriately respond to denials of requested health care services. Denials of service can cause frustration and anger. However, by applying your skills to one issue at a time, you will help each patient understand the process and how to cope in ways that maximize health. These skills will be useful to anyone trying to work their way through the health care maze, whether your patients, family, or yourself.
At the conclusion of this activity, members of the interprofessional team should be able to better:
Define the spheres of influence, their roles, and interactions in the utilization review process
Recognize the various levels of review and how to advocate on a patient's behalf at each level
Identify common utilization review topics
Define the difference between an internal and external review, and determine when an appeal is appropriate
Recognize the reasons for denials and how to put together an appeal that addresses the identified deficiencies
Identify various sources of evidence-based medicine (EBM) and how to use EBM to support an appeal
Integrate clinical, health plan language, and medical reference material to create an appropriate appeal letter
Faculty includes:
Linda G. Sheff, MBA, CHCQM
About the Authors
Members of the Education Committee, Planners, and Faculty have no relevant financial relationships with ineligible companies to disclose.
ACCREDITATION & CREDIT
In support of improving patient care, the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physicians
ABQAURP designates this enduring material for a maximum of 4.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nurses
This activity is designated for 4.5 nursing contact hours.
The American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) is an approved provider with the Florida Board of Nursing to provide continuing education for nurses. ABQAURP designates this activity for 4.5 contact hours through the Florida Board of Nursing. Provider # 50-94.
This program is approved for Category 2 credit by the American Osteopathic Association.
This activity was planned by and for the healthcare team, and learners will receive 4.5 Interprofessional Continuing Education (IPCE) credits for learning and change.
This activity is valid from April 17, 2025 through April 16, 2028. (Previously valid March 8, 2022 through March 7, 2025. Reviewed March 2025.)
Pricing:
Diplomate Members $170.00
Professional Members $190.00
Non-Members $230.00
Credits awarded per Session. See individual Sessions for further details.
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About this item
This online PDF text-based course introduces the concepts, language, and processes of Utilization Review (UR) for interprofessional providers acting as patient advocates, including physicians, nurses, medical office staff, professional patient advocates, and other individuals that want to expand their knowledge of UR and its role in managed health care.
Managed Care and the practice of UR of health care services are accepted methods for dealing with health care costs. Ongoing changes in the federal government's role in the health care system make it even more important to understand UR concepts, how UR affects patient access to care, and what to do when a requested health care service is denied (adverse determination). The Affordable Care Act created access to "external reviews", an additional level of review that allows review of denied health care by an independent review organization (IRO) that is unrelated to the insurance carrier. Therefore, knowledge of the UR process, various levels of review, and how to negotiate in this environment is a powerful asset to facilitate the patient's navigation through the complexities of the health care system. The appropriate use of the grievance and appeals process is an essential skill. It is in every patient advocate's best interest to become familiar with the principles of UR to utilize this knowledge to maximize patients' access to medically necessary care.
This course provides a detailed explanation of how advocacy professionals navigate the UR process to obtain the best outcomes for their clients. Learners will be well-prepared to play a needed role in assisting patients with understanding health care options and how to appropriately respond to denials of requested health care services. Denials of service can cause frustration and anger. However, by applying your skills to one issue at a time, you will help each patient understand the process and how to cope in ways that maximize health. These skills will be useful to anyone trying to work their way through the health care maze, whether your patients, family, or yourself.
At the conclusion of this activity, members of the interprofessional team should be able to better:
Faculty includes:
Linda G. Sheff, MBA, CHCQM
About the Authors
Members of the Education Committee, Planners, and Faculty have no relevant financial relationships with ineligible companies to disclose.
ACCREDITATION & CREDIT
In support of improving patient care, the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physicians
ABQAURP designates this enduring material for a maximum of 4.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nurses
This activity is designated for 4.5 nursing contact hours.
The American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) is an approved provider with the Florida Board of Nursing to provide continuing education for nurses. ABQAURP designates this activity for 4.5 contact hours through the Florida Board of Nursing. Provider # 50-94.
This program is approved for Category 2 credit by the American Osteopathic Association.
This activity was planned by and for the healthcare team, and learners will receive 4.5 Interprofessional Continuing Education (IPCE) credits for learning and change.
This activity is valid from April 17, 2025 through April 16, 2028. (Previously valid March 8, 2022 through March 7, 2025. Reviewed March 2025.)
Pricing:
Diplomate Members $170.00
Professional Members $190.00
Non-Members $230.00
Managed Care and the practice of UR of health care services are accepted methods for dealing with health care costs. Ongoing changes in the federal government's role in the health care system make it even more important to understand UR concepts, how UR affects patient access to care, and what to do when a requested health care service is denied (adverse determination). The Affordable Care Act created access to "external reviews", an additional level of review that allows review of denied health care by an independent review organization (IRO) that is unrelated to the insurance carrier. Therefore, knowledge of the UR process, various levels of review, and how to negotiate in this environment is a powerful asset to facilitate the patient's navigation through the complexities of the health care system. The appropriate use of the grievance and appeals process is an essential skill. It is in every patient advocate's best interest to become familiar with the principles of UR to utilize this knowledge to maximize patients' access to medically necessary care.
This course provides a detailed explanation of how advocacy professionals navigate the UR process to obtain the best outcomes for their clients. Learners will be well-prepared to play a needed role in assisting patients with understanding health care options and how to appropriately respond to denials of requested health care services. Denials of service can cause frustration and anger. However, by applying your skills to one issue at a time, you will help each patient understand the process and how to cope in ways that maximize health. These skills will be useful to anyone trying to work their way through the health care maze, whether your patients, family, or yourself.
At the conclusion of this activity, members of the interprofessional team should be able to better:
- Define the spheres of influence, their roles, and interactions in the utilization review process
- Recognize the various levels of review and how to advocate on a patient's behalf at each level
- Identify common utilization review topics
- Define the difference between an internal and external review, and determine when an appeal is appropriate
- Recognize the reasons for denials and how to put together an appeal that addresses the identified deficiencies
- Identify various sources of evidence-based medicine (EBM) and how to use EBM to support an appeal
- Integrate clinical, health plan language, and medical reference material to create an appropriate appeal letter
Faculty includes:
Linda G. Sheff, MBA, CHCQM
About the Authors
Members of the Education Committee, Planners, and Faculty have no relevant financial relationships with ineligible companies to disclose.
ACCREDITATION & CREDIT
In support of improving patient care, the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physicians
ABQAURP designates this enduring material for a maximum of 4.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nurses
This activity is designated for 4.5 nursing contact hours.
The American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) is an approved provider with the Florida Board of Nursing to provide continuing education for nurses. ABQAURP designates this activity for 4.5 contact hours through the Florida Board of Nursing. Provider # 50-94.
This program is approved for Category 2 credit by the American Osteopathic Association.
This activity was planned by and for the healthcare team, and learners will receive 4.5 Interprofessional Continuing Education (IPCE) credits for learning and change.
This activity is valid from April 17, 2025 through April 16, 2028. (Previously valid March 8, 2022 through March 7, 2025. Reviewed March 2025.)
Pricing:
Diplomate Members $170.00
Professional Members $190.00
Non-Members $230.00
Course/Activity Information
This course has been reviewed and contains updated material. Learners may retake this course, claim continuing education credits, and receive an updated certificate, if you have taken it in the past.
This course is intended for Physicians of all specialties, Nurses, and Other Health Care Professionals with appropriate CME/CE credit offered for each profession.
All participants must achieve a final assessment score of at least seventy percent (70%) for recertification and continuing education credits. You have 60 days to complete the course after ordering.
This activity is valid from April 17, 2025, through April 16, 2028. (Previously valid March 8, 2022 through March 7, 2025. Reviewed March 2025.)
About the Author:
Linda G. Sheff, MBA, CHCQM
Linda G. Sheff, MBA, is the author of the Advocacy CMR program and the former President and Chief Executive Officer of Physicians' Review Network, Inc. (PRN). Ms. Sheff received a Bachelor of Sciences and a Master of Business Administration from the State University of New York at Buffalo and is a fellow of the American Board of Quality Assurance and Utilization Review Physicians. Ms. Sheff has an extensive background in healthcare, medical reviews, and many years of managerial experience in laboratory services, information technology, and hospital administration before concentrating on the utilization review industry in 1989.
Other information
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Contact:Contact Education
- Training Hours: 4.50
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