Common use of Retrospective Review of Preauthorized Services Clause in Contracts

Retrospective Review of Preauthorized Services. We may only reverse a preauthorized treatment, service or procedure on retrospective review when: • The relevant medical information presented to Us upon retrospective review is materially different from the information presented during the Preauthorization review; • The relevant medical information presented to Us upon retrospective review existed at the time of the Preauthorization but was withheld or not made available to Us; • We were not aware of the existence of such information at the time of the Preauthorization review; and • Had We been aware of such information, the treatment, service or procedure being requested would not have been authorized. The determination is made using the same specific standards, criteria or procedures as used during the Preauthorization review.

Retrospective Review of Preauthorized Services. We may only reverse a preauthorized treatment, service or procedure on retrospective review when: •  The relevant medical information presented to Us upon retrospective review is materially different from the information presented during the Preauthorization review; •  The relevant medical information presented to Us upon retrospective review existed at the time of the Preauthorization but was withheld or not made available to Us; •  We were not aware of the existence of such information at the time of the Preauthorization review; and •  Had We been aware of such information, the treatment, service or procedure being requested would not have been authorized. The determination is made using the same specific standards, criteria or procedures as used during the Preauthorization review.

Retrospective Review of Preauthorized Services. We may only reverse a preauthorized treatment, service or procedure on retrospective review when: • The relevant medical information presented to Us upon retrospective review is materially different ditferent from the information presented during the Preauthorization review; • The relevant medical information presented to Us upon retrospective review existed at the time of the Preauthorization but was withheld or not made available to Us; • We were not aware of the existence of such information at the time of the Preauthorization review; and • Had We we been aware of such information, the treatment, service or procedure being requested would not have been authorized. The determination is made using the same specific standards, criteria or procedures as used during the Preauthorization review.