Retrospective Review
Retrospective review is the process of determining initial clinical coverage:1
- 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 a plan sponsor-specific member precertification list.
- Is not conducted for services not on a precertification list (for example, office visits, behavioral health outpatient counseling).
- 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 Women's Health Programs, such as the Moms-to-Babies Maternity Management 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.