Medical - retrospective review
Retrospective review is the process of determining coverage after a member has been discharged or a service has been provided. Retrospective reviews are performed:
Retrospective review is available when:
Retrospective review does not occur for claims for:
Retrospective review includes the following processes:
Retrospective review does not include a preferred/in-network level of benefits determination for routine or scheduled services performed by a nonparticipating provider.
Note: More stringent state requirements may supersede the requirements of this policy.
1 For these purposes, “coverage” means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is required to comply with Aetna's utilization management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.