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Retrospective Review

Precertification | Concurrent Review | Retrospective Review

Medical - retrospective review 

Retrospective review is the process of determining coverage1 for a clinical service:

  • By applying guidelines/criteria to support the adjudication of eligible claims 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:

  • Is not available for claims for:
  • May be necessary to process an eligible claim for emergency inpatient services, some elective inpatient services and the procedures/services requiring precertification under the terms of a member's plan when Aetna is not notified of an admission or service at the time the services are provided or precertification is not obtained
    • Retrospective review may be necessary when the clinical condition of a member prevents notification during an inpatient stay or a member's primary coverage is misidentified
  • Is used to identify and refer members, when appropriate, to covered specialty programs, including Aetna Health ConnectionsSM case management and disease management, behavioral health, National Medical Excellence® and women's health programs, such as the Beginning Right® Maternity Program
  • Is used to identify and refer potential quality and/or utilization issues and to initiate follow-up actions
  • Is used to identify, refer and review (as applicable) patient safety events
  • Does not include a preferred/in-network level of benefits determination for routine or scheduled services performed by a nonparticipating provider

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.