Retrospective reviews
A retrospective review is the process of determining coverage after treatment has been given.
3 business days
After the last approved day, for a subsequent inpatient request.
5 business days
After the performed service, for an additional service.
Questions?
Call 855-579-3879
When is retrospective review available?
Retrospective review is available to a provider when all of the following criteria is met:
- Confirming member eligibility and the availability of benefits.
- The service has not been submitted for payment or processing.
And one of the following
- 1If the health plan authorized an initial inpatient request, a subsequent request will be accepted for review within 3 business days of the last approved day.
- 2An additional service was identified as necessary when the original authorized service was performed. Requests for this additional service will be accepted within 5 business days of the performed service.
Retrospective review is not available for
- Elective ambulatory or inpatient services on the prior authorization list for which prior authorization did not occur before providing the service.
- Services requiring notification within 3 business days that did not meet notification requirements (notification of inpatient admissions is required within 3 business days of admission date).
- Services not included on the prior authorization list.
- Services that do not require prior authorization under the terms of a member’s plan.
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