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A utilization review summary is the clinical document a treating clinician or facility submits to a payer to justify continuing an authorized course of treatment or level of care. Payers call the process concurrent or continued-stay review. It compiles current symptoms, objective measures, risk status, treatment response, and the barriers to step-down. Most run 300 to 600 words or fill a payer portal form.
UR staff or care coordinators compile it; a licensed treating clinician owns and signs the clinical assertions
Payer care managers and physician reviewers; the chart and auditors when a copy is filed
300 to 600 words · 15 to 25 minutes by hand (clinical team estimate)
Structured medical-necessity summary (compare: prior authorization request, appeal letter)
During an authorized episode of care, at each concurrent or continued-stay review interval the payer sets
Payer policy, not statute, defines the document; federal and state law set the payer's deadlines and denial duties
A utilization review summary is the document a treating clinician or facility submits to a payer to support continuing an already-authorized course of treatment or level of care. Utilization review itself entered US law with the 1965 Medicare statute, which made a hospital utilization review plan a condition of participation (now 42 CFR 482.30), ran through the Professional Standards Review Organizations created in 1972 and the peer review organizations that replaced them under TEFRA in 1982, and moved into private managed care in the late 1980s and 1990s, with URAC incorporated in 1990 to write the first national utilization review standards. The clinician-facing document this page covers answers to many names: concurrent review, continued stay review, clinical review, level of care review, treatment report, and, in outpatient behavioral health, the outpatient treatment report or request (OTR).
Two boundaries do the most work. First, the summary is the input, not the decision: the clinician supplies clinical information, and the determination belongs to the payer, whose adverse medical-necessity decisions generally must be made by a physician reviewer. Second, no US federal law requires an outpatient behavioral health clinician to produce a standalone utilization review summary at all. The utilization review regulations that exist (42 CFR 482.30 and 42 CFR Part 456) bind hospital and Medicaid facility review committees, not treating therapists, so in outpatient care the obligation to submit clinical information is contractual, defined by the payer's utilization management policy. That makes this document the mid-treatment sibling of the prior authorization letter: authorization gets care started, and the utilization review summary keeps it authorized.
Utilization review staff, care coordinators, and treating clinicians in inpatient psychiatric units, residential and substance use programs, partial hospitalization, and intensive outpatient programs produce them on a payer-set cadence, often every few days at the higher levels of care. Outpatient therapists meet the same document as the outpatient treatment report: routine weekly psychotherapy rarely needs prior authorization, but some plans begin concurrent review once a client passes a session threshold, commonly somewhere in the 10 to 20 visit range. Use this format whenever a payer asks you to justify continuing care that is already authorized. Before care starts, that request is a prior authorization; after a denial, it becomes a peer-to-peer conversation or a written appeal; and the internal document that tracks the same question for clinical rather than payer purposes is the treatment plan review.
Authorization and review header. Member identifiers, plan, authorization number, current level of care, the authorization period, units used against units approved, and the review type. Pitfall: mismatches between this header and the authorization on file. Wrong dates, codes, or units produce administrative denials such as CO-197, and no amount of clinical writing further down the page fixes a clerical mismatch up here.
Diagnosis and current presentation. Working diagnoses with ICD-10 codes, today's symptoms with severity and frequency, functional impairment, and objective measures with dates and direction of change. Pitfall: restating the admission picture. Reviewers read this section against your last submission, and payer guidance on outpatient treatment requests explicitly returns forms that change the dates without changing the clinical information.
Current risk status. Suicidality, self-harm, danger to others, and withdrawal or medical risk, dated today and compared with the last review. Pitfall: a risk section that never changes. Static copy-forward risk language is an audit red flag, and it quietly argues the client is stable enough to step down.
Treatment response since last review. Interventions delivered, attendance, measurable response or lack of response, medications and adherence, and what you changed when response stalled. Pitfall: narrating attendance instead of response. Nine of nine days attended proves the program happened; a falling symptom score and a widening window of function prove it is working and still needed.
Continued-stay rationale tied to criteria. Name the criteria set the payer applies (ASAM for substance use, LOCUS or CALOCUS-CASII for mental health levels of care, InterQual or MCG on the general medical side), the specific criterion or dimension met, and why a lower level of care is not appropriate today. Pitfall: arguing that the client would benefit from more care. Benefit is the wrong test; the reviewer is deciding whether the member can be safely and adequately treated at a lower level right now, so answer exactly that question.
Step-down plan and barriers. The discharge or step-down plan, the specific barriers preventing it today, and the measurable thresholds that will trigger it. Pitfall: omitting this section. With no step-down plan on the page, the summary reads as an open-ended stay, which is precisely what level-of-care criteria are built to end.
Request and sign-off. The days, sessions, or dates requested, who compiled the summary, and the licensed treating clinician's attestation of the clinical content, with a supervisor co-signature where a pre-licensed clinician drafted it. Pitfall: a vague or overlapping request. Units without dates, or dates that overlap the current authorization, hand the plan an administrative reason to return the request unread.
UTILIZATION REVIEW SUMMARY (concurrent / continued-stay review) The format is a convention; the payer's criteria set defines the content. Confirm the plan's form, portal fields, and review cadence. AUTHORIZATION AND REVIEW Member: ____________________ ID: ____________ DOB: _____________ Payer / plan: ______________________ Auth #: ____________________ Level of care: [ ] OP [ ] IOP [ ] PHP [ ] Residential [ ] Inpatient Auth period: _________ to _________ Units used / approved: __ / __ Review date: _________ Type: [ ] scheduled [ ] payer request DIAGNOSIS AND CURRENT PRESENTATION Diagnoses (ICD-10): _______________________________________________ Symptoms today, severity and frequency: ___________________________ ___________________________________________________________________ Objective measures (instrument, score, date, change): _____________ Functional impairment: ____________________________________________ CURRENT RISK STATUS (dated; compare with last review) Suicidality / self-harm: __________________________________________ Danger to others: _____________ Withdrawal / medical: ____________ Change since last review: _________________________________________ TREATMENT RESPONSE SINCE LAST REVIEW Interventions and attendance: _____________________________________ Response or lack of response: _____________________________________ Medications and adherence: ________________________________________ CONTINUED-STAY RATIONALE Criteria set and edition: _________________________________________ Criterion / dimension met: ________________________________________ Why a lower level is not appropriate today: _______________________ ___________________________________________________________________ STEP-DOWN PLAN AND BARRIERS Plan and target level: ____________________________________________ Barriers today: ___________________________________________________ Thresholds that trigger step-down: ________________________________ REQUEST AND SIGN-OFF Days / sessions requested: ___________ Dates: ____________________ Compiled by: ______________________ Date: ________________________ Licensed clinician (clinical content): ____________________________ Credential: ____________ Signature / date: _______________________
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: the clinical team at an intensive outpatient program submits a scheduled concurrent review to continue an adult client in IOP care beyond the initial authorization. All details are fictional.
Utilization Review Summary (concurrent review). Member: M.T. · DOB: 04/12/1988 · Plan: Harborline Health (commercial) · Auth #: HL-26-40917 · Level of care: IOP · Auth period: 07/01/2026 to 07/24/2026, 9 of 12 days used · Review date: 07/21/2026, scheduled concurrent review
Diagnosis and current presentation: Major depressive disorder, recurrent, moderate (F33.1); generalized anxiety disorder (F41.1). Depressed mood most of the day, early-morning waking 4 to 5 nights per week, impaired concentration, and low motivation. PHQ-9 14 today (07/21) from 19 at admission (07/01); GAD-7 11 from 15. Working half days only; missed 3 of the last 10 scheduled workdays. LOCUS composite 17 today from 19 at admission, scored 07/21.
Current risk status (07/21): Passive thoughts of death without plan, intent, or preparatory behavior, unchanged from the 07/14 review. No self-harm, no aggression, no withdrawal or acute medical risk. Safety plan reviewed 07/16; client named two reachable supports and used one this week.
Treatment response since last review: Attended 9 of 9 IOP days (3 days per week: group CBT, behavioral activation, weekly individual session, psychiatric consultation). Behavioral activation homework completed 5 of 6 assigned days this week, up from 2 of 6 at the last review. Sertraline increased from 50 mg to 100 mg on 07/08 after partial response; adherent by report and refill record, initial nausea resolved. Sleep extended from about 4 to about 5.5 hours.
Continued-stay rationale: Criteria set per the plan's provider manual: LOCUS. Composite 17 remains in the Level 3 range (high intensity community based services), driven by functional status and recovery environment dimensions. A step to weekly outpatient therapy is not appropriate today: symptom severity still prevents full-day work function, the 07/08 medication increase needs monitored titration through week 4, and gains have not yet held on non-program days.
Step-down plan and barriers: Target: weekly individual therapy with the current clinician plus psychiatry every 4 weeks. Thresholds: PHQ-9 below 10 sustained for 2 weeks, full-day work tolerance, stable sleep. Barriers today: residual early-morning waking, impaired concentration, and the active titration.
Request and sign-off: 10 additional IOP days, 3 days per week, 07/27/2026 to 08/14/2026. Compiled by R. Okafor, care coordinator, 07/21/2026. Clinical content reviewed and attested by D. Whitfield, LCSW, treating clinician, 07/21/2026.
This sample is fictional and for educational purposes. It does not describe a real client, clinician, or health plan.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsNo regulation requires you to file the utilization review summary in the clinical record; filing it is a convention, and many programs keep concurrent review paperwork in a utilization review or billing file instead. Once filed in the record, it inherits the record's retention clock, commonly 5 to 10 years in the US depending on program and state, with minors' records held past majority. Wherever it lives, keep its voice distinct from the treatment record: the summary and the psychotherapy progress note serve different audiences, and copying the same narrative across dates or documents is a documented audit red flag. Feed the summary from measurement instead, with current dated scores from an outcome measure note workflow, medication changes, and functional specifics. Substance use programs get one genuine easing: under the 2024 revision of 42 CFR Part 2 (compliance date February 16, 2026), a single properly drafted consent covering treatment, payment, and health care operations now reaches utilization review disclosures, replacing the per-disclosure consents that used to complicate concurrent review. Clinicians in Canada and Australia rarely face US-style concurrent review at all; the closest analogues are workers' compensation and disability insurer reports, with retention set by provincial or state health-records law.
The payer-facing mechanics run on two clocks, and only one of them is yours. No federal rule sets a deadline for when the treating clinician must submit a concurrent review; that timeline is contractual. The payer's clock is law: urgent concurrent decisions run in as little as 72 hours under ERISA and Medicaid managed care rules, CMS's interoperability rule holds standard prior authorization decisions for impacted plans to 7 calendar days from January 1, 2026, and a Medicaid managed care plan that misses its deadline has, by regulation, issued a denial. The law also protects a client mid-course: under the ERISA concurrent-care rule, reducing or ending an approved course of treatment early is an adverse benefit determination requiring advance notice and appeal rights, and most state utilization review statutes require a physician, often of the same or similar specialty, to make that determination after offering a peer-to-peer. Parity law reaches the criteria themselves: concurrent review is a classic nonquantitative treatment limitation, and plans still owe a comparative analysis of those criteria on request even while the 2024 MHPAEA rule sits under a non-enforcement posture. When a denial does land, read the remittance next to the billing note: an authorization mismatch surfaces as CO-197, an administrative code, while a true medical-necessity denial arrives as code 50, and the two have entirely different fixes.
When the HHS Office of Inspector General audited denials issued by 15 of the largest Medicare Advantage organizations (report OEI-09-18-00260, April 2022), it found that 13 percent of denied prior authorization requests actually met Medicare coverage rules, and 18 percent of denied payment requests met both coverage and billing rules, with plans applying clinical criteria not found in Medicare coverage rules and requesting documentation they did not need. KFF's analysis of HealthCare.gov insurers adds the consumer side: nearly one in five in-network claims was denied in 2023, fewer than 1 percent of denials were appealed, and insurers upheld most of the appeals they did receive. The uncomfortable lesson is that criteria mismatch, not documentation quality, drives many denials, which makes the summaries that survive review the ones engineered against the named criteria. The BastionGPT Clinical Advisory Board sees the same errors most often in utilization review summaries:
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For outpatient behavioral health, no. No US federal statute requires a treating clinician to produce a standalone utilization review summary; the duty to submit clinical information for continued care comes from the payer contract and its utilization management policy. The utilization review regulations that do exist (42 CFR 482.30 for hospitals, 42 CFR Part 456 for Medicaid facilities) bind facility review committees, and the ERISA claims rule regulates the payer's deadlines and notices, not your prose. Treat the document as payer policy with legal consequences: contractual in origin, but decisive for whether authorized care continues.
Across ASAM, LOCUS and CALOCUS-CASII, InterQual, and MCG, reviewers look for the same core: current symptoms with severity and objective measures, functional impairment, current risk status, response or lack of response to treatment, medications and adherence, the step-down plan with the barriers preventing it today (the same planning that later feeds the discharge summary), an explicit statement of why a lower level of care is not appropriate right now, the specific criterion or dimension met, and the exact days or sessions requested with dates. The strongest single upgrade is objective measurement with dates: a score that moved is evidence of response, and a score that has not yet reached target is evidence of continued need.
Most run 300 to 600 words, and many payers replace free text entirely with portal fields or a fixed outpatient treatment report form, in which case length is decided for you. No published study isolates how long clinicians spend drafting one, a gap worth remembering when a plan calls the burden minimal; the AMA's 2024 physician survey found practices completing an average of 39 prior authorization requests per physician per week and spending about 13 hours a week on them. Write to the criteria, not to a word count: a short summary that names the criterion beats a long one that narrates the stay.
Timing. A prior authorization request is submitted before care starts to obtain initial approval; the utilization review summary is submitted during care to continue an approval that already exists, which is why payers call the process concurrent or continued-stay review. The distinction carries legal weight: under the ERISA concurrent-care rule, cutting an approved course of treatment mid-stream is an adverse benefit determination with advance-notice and appeal rights, protections a fresh authorization request does not enjoy. Downstream of both sit the peer-to-peer conversation and, after a denial, the written appeal.
Treat it as a denial, not a lapse. If the plan approved a course of treatment and is reducing or ending it early, ERISA's concurrent-care rule makes that an adverse benefit determination: the plan must give advance notice and an appeal opportunity before the benefit stops, and urgent concurrent appeals run on an expedited clock measured in hours, not weeks. The fastest lever is usually a peer-to-peer review with the plan's physician reviewer, which many state utilization review laws require the plan to offer, often with a physician of the same or similar specialty, before the determination becomes final. If the peer-to-peer is refused or too slow, file the expedited internal appeal and preserve external review rights.
General medical reviews run on InterQual or MCG. In behavioral health, the ASAM Criteria dominates substance use placement (its Fourth Edition, released October 2023, is rolling into payer use through 2026), and mental health level-of-care decisions increasingly use LOCUS for adults and CALOCUS-CASII for ages 6 to 18. You are entitled to know which one applies: Medicaid managed care enrollees may obtain the criteria relied on free of charge, ERISA and ACA appeal rules give claimants the rule behind a denial, and several state laws require disclosure on request. Ask in writing, then write the summary to the named criterion.
They can compile and transmit it, and in facility settings a utilization review coordinator usually does. The clinical assertions, though, must come from the licensed treating clinician, and pre-licensed drafters typically need a supervisor's co-signature under state licensure and payer credentialing rules. The asymmetry is worth remembering: on the payer's side, most state utilization review laws require that an adverse medical-necessity determination be made by a physician, so the exchange is licensed clinician to licensed reviewer even when other staff carry the paperwork. Time spent on the review itself is generally administrative and not separately billable.
No regulation requires it to be filed in the clinical record; filing is a convention, and many programs keep concurrent review documents in a utilization review or billing file instead. Once filed in the record, it inherits the record's retention clock: commonly 5 to 10 years for US federal programs and state rules, longer for minors. Clinicians in Canada and Australia rarely face US-style concurrent review; the closest analogues are workers' compensation and disability insurer reports, and retention follows provincial or state law (Ontario physicians keep records at least 10 years from the last entry, and several Australian states require 7 years for adults or until a child patient turns 25).
Yes. Give it your recent notes, the current scores, and the criteria set the plan applies, and it drafts the summary with the current presentation, response since last review, the named criterion, the step-down barriers, and a specific request, then checks that nothing was cloned from the prior submission. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.