Utilization Review/Medical Necessity Review Note

Patient: [name, MRN, DOB]

Encounter: [encounter/account number]

Facility/Location: [facility, unit/bed]

Attending Service: [service and provider]

Admission Date: [date] | Hospital Day: [HD#]

Payer: [payer name and plan type]

Review Date/Time: [date and time]

Review Type: [initial admission / concurrent / retrospective / LOC reassessment]

Reviewer: [name, credentials, role]

Clinical Summary and Current Status

[3–6 sentence narrative including: admitting/working diagnosis; key comorbidities affecting risk or management; major events or procedures since admission; treatment response with objective supporting data; current documented LOC and unit type, anchored to specific timeframe] (Use objective, time-anchored language. Separate documented facts from recommendations. If information is unavailable, state explicitly.)

Criteria Applied: [MCG / InterQual / Facility-approved criteria] [version/date if available]

LOC Recommendation: [no change / recommend change from [current] to [proposed]] (Only include if different from current documented status.)

Medical Necessity Indicators

Severity of Illness: [relevant indicators with measured values, dates, and trends—e.g., vital sign instability, mental status changes, laboratory abnormalities, imaging findings, high-risk comorbidities affecting discharge safety] (Include only documented, objective findings supporting current LOC.)

Intensity of Service: [relevant indicators with specifics—e.g., IV medications requiring monitoring/titration, oxygen delivery method and requirements, telemetry or protocol-driven monitoring, pending procedures requiring inpatient setting, active time-sensitive consults] (Include only documented services requiring hospital-level resources.)

Changes Since Last Review: [new findings, escalations/de-escalations, treatments started/stopped] (Include for concurrent reviews only.)

Continued Stay Rationale and Discharge Planning

[2–4 sentence rationale: why discharge or LOC downgrade is not appropriate today, linked to unresolved acute issues and specific risks; expected plan for next 24–48 hours]

Anticipated Disposition: [home / home with services / SNF / IRF / LTACH / hospice / other]

Estimated Discharge Date: [date] or pending [milestone]

Barriers to Discharge: [barrier description — owner/action — status — expected timeframe] (List each active barrier on separate line. If none, state "No active barriers" or "Discharge planning deferred due to [reason].")

Determination and Next Review

Authorization Status: [approved (days/dates) / pending / denied / appeal in progress / not required] [reference number if applicable]

Determination: [meets criteria for continued stay at current LOC / does not meet criteria—escalated to physician advisor / recommend LOC change from [X] to [Y]]

Rationale: [1–3 sentences referencing strongest clinical indicators supporting determination]

Next Review: [date/time] or within [X] hours per [requirement]

Reassessment Criteria: [specific clinical milestones to evaluate at next review]

Reviewer Signature: [name, credentials, role]