Which utilization review phase involves auditing medical records after care has been delivered to assess appropriateness?

• A. Prospective
• B. Retrospective
• C. Concurrent
• D. Audit

Answer: (B)

Retrospective utilization review is the process of auditing medical records after care has been delivered to assess whether the services were appropriate and medically necessary. In this approach, the chart is reviewed post-treatment to verify that documentation supports the diagnosis, the level of care, the interventions used, and that they align with clinical guidelines and payer requirements. This post-hoc check helps with quality improvement and informs reimbursement decisions, identifying potential overuse, underuse, or documentation gaps. It contrasts with prospective review (approval before care) and concurrent review (monitoring during care). While auditing can occur in various contexts, the phase described here is retrospective because it occurs after the care has been provided.