Retrospective Reviews

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.

• If 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.
• An 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.

• 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.