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 Connections^SM 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.