Retrospective Review

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:

• After confirming member eligibility and the availability of benefits at the time the service was provided
• Using clinical guidelines/criteria to support the coverage determination process
  • Providers should submit supporting clinical documentation with the request for payment

Retrospective review is available when:

• Precertification/notification requirements were met at the time the service was provided, but the dates of service do not match the submitted claim.
• Aetna converts from secondary payer to primary payer at the time of inpatient claims adjudication.

Retrospective review does not occur for claims for:

• Elective ambulatory or inpatient services on the Aetna Participating Provider Precertification List or the Aetna Behavioral Health Precertification List for which precertification did not occur before providing the service
• Emergency inpatient services on the Aetna Participating Provider Precertification List or the Aetna Behavioral Health Precertification List that did not meet notification requirements
  • Notification of all inpatient admissions is required within one business day of the admission date
• Services not included on a precertification list
• Services that do not require precertification under the terms of a member’s plan

Retrospective review includes the following processes:

• The identification and referral of members, when appropriate, to covered specialty programs, including Aetna Health Connections^SM case management and disease management, behavioral health, National Medical Excellence Program®, and women’s health programs, such as the Beginning Right® Maternity Program
• The identification and referral of potential quality and/or utilization issues for follow-up
• The identification, referral and review (as applicable) of patient safety events  

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.