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Guidelines for Determining Coverage | Clinical Policy Bulletins | Medicare | Payment Policy | Dispute Process

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Medical - Retrospective Review

Retrospective review is the process of determining coverage1 for a clinical service:
  • By applying guidelines/criteria for claims adjudication after the opportunity for precertification or concurrent review has passed.

    • Providers should submit supporting clinical documentation with the request for payment.

  • After confirming member eligibility and the availability of benefits at the time the service was provided.

Retrospective review:

  • Applies to the procedures and services on the Aetna Participating Provider Precertification List, the Aetna Behavioral Health Precertification List and those procedures and services requiring precertification under the terms of a member's plan.

  • Is not conducted for services not included on a precertification list (for example, office visits, behavioral health outpatient counseling) or that do not require precertification under the terms of a member's plan.

  • May be necessary to review coverage requests when precertification is not obtained (for example, clinical condition of a member prevents notification during an inpatient stay, primary coverage misidentified).

  • Is performed for inpatient stays prior to claims payment when an initial clinical review for the level of services (for example, intensive care, surgical) has not occurred.

  • Is used to identify and refer members, when appropriate, to covered specialty programs, including Aetna Health ConnectionsSM Disease Management, Case Management, National Medical Excellence, Behavioral Health and the Beginning RightSM Maternity Program.

  • Is used to identify and refer potential quality and/or utilization issues and to initiate follow-up actions.

  • Does not include a preferred/in-network level of benefits determination for non-emergent services performed by a nonparticipating provider.

  • Is not conducted for procedures/services for Medicare Advantage Private Fee-for-Service (PFFS) plan members.

More stringent state requirements supersede 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.
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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 patient management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.