Utilization Review Worksheet
Client name:
ID #:
Period being reviewed:
Reviewer:
1. Does the original screening show medical necessity and meet the placement
mandates of the Center?
Yes
No
Please Explain:
2. After reviewing the assessment is there sufficient documentation to support
Medical Necessity and the Diagnosis based on diagnostic criteria outlined in
the DSM-IV-TR?
Yes
No
Please Explain:
3. If there is an assessed barrier is it addressed in the Recovery Plan?
Yes
No
4. Is the focus of the recovery plan the same as indicated in the
Assessment/Bridge?
Yes
No
Please explain:
5. Upon reviewing all documentation, were the methods of service and the
length of treatment provided appropriate for the diagnosis?
Yes
No
Please Explain:
6. Were there other services that could have been recommended (Community
Partners) that may have helped the client to achieve recovery?
Yes
No
Please explain:
7. If the client was making little progress (or demonstrated patterns of no
show/broken appointments, crisis calls, hospitalizations etc.) did the clinician
make changes to the Recovery Plan/Service Level?
Yes
No
Please explain:
8. Do the recorded services match the frequency/intensity of the planned
services?
Yes
No
Please explain:
9. Is there documentation that the client made progress, and is the frequency
intensive enough to lead to recovery?
Yes
No
Please explain:
10. Does the intensity of the Recovery Plan match the service level?
Yes
No
Please Explain:
11. If the client has not been seen for 45 days is there documentation of outreach
or discharge?
Yes
No
Please explain:
12. If no objectives have been reached at the first review cycle is there
documentation to support continuing with the same recovery goals or
continuing treatment but adjusting or changing the recovery goals?
Yes
No
Please explain:
13. Could the clinician/clinical team have reduced Center costs by avoiding an
Out
Of Home Placement or Hospitalization during the treatment episode without
Jeopardizing quality of care for the client?
Yes
No
Please Explain: