Retrospective Reviews. If We have all information necessary to make a determination regarding a retrospective claim, We will make a determination and notify You and Your Provider within 30 calendar days of the receipt of the request. If We need additional information, We will request it within 30 calendar days. You or Your Provider will then have 45 calendar days to provide the information. We will make a determination and provide notice to You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of all or part of the requested information or the end of the 45-day period. Once We have all the information to make a decision, Our failure to make a Utilization Review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an internal Appeal.
Retrospective Reviews. Contractor agrees, on a quarterly basis, to conduct selective retrospective reviews of the following types of cases: i) cases where denials were issued upfront, but the Member did not appeal; and ii) cases where the original denial was appealed by the Member and the decision was upheld by the Contractor’s appeal reviewer, triggering an automatic referral to Maximus, CMS’ independent review organization. Additionally, Contractor will review cases where the original Prior Authorization request was denied that the Member appealed, which led the Contractor’s appeal reviewer to overturn the denial. Contractor will use this added quarterly review process to identify key learnings that it can use to improve its Prior Authorization processes.
Retrospective Reviews. If a pre-service or a care coordination review was not performed, a retrospective review will be done to review services that have already been provided to determine if they are Medically Necessary. Retrospective review is performed when Anthem Blue Cross has not been notified of the services the Member received and therefore is unable to perform the appropriate review. It is also performed when pre-service or care coordination review has been done, but services continue longer than originally certified. Retrospective review may also be performed for the evaluation and audit of medical documentation after services have been provided, whether or not pre-service or care coordination review was performed. Such services which have been retrospectively determined to not be Medically Necessary and appropriate will be retrospectively denied certification. The Medical Necessity Review Process Anthem Blue Cross works with Members and Members’ health care providers to cover Medically Necessary and appropriate care and services. While the types of services requiring review and the timing of the reviews may vary, Anthem Blue Cross is committed to ensuring that reviews are performed in a timely and professional manner. The following information explains Anthem Blue Cross’ review process.
1. A decision on the medical necessity of a pre-service request will be made no later than five (5) business days from receipt of the information reasonably necessary to make the decision, and based on the nature of the Member’s medical condition. When the Member's medical condition is such that the Member faces an imminent and serious threat to their health, including the potential loss of life, limb, or other major bodily function and the normal five day timeframe described above would be detrimental to your life or health or could jeopardize your ability to regain maximum function, a decision on the medical necessity of a pre-service request will be made no later than 72 hours after receipt of the information reasonably necessary to make the decision (or within any shorter period of time required by applicable federal law, rule, or regulation).
2. A decision on the medical necessity of a care coordination request will be made no later than one (1) business day from receipt of the information reasonably necessary to make the decision, and based on the nature of the Member’s medical condition. However, care will not be discontinued until the Member’s Physician has been notified and a...
Retrospective Reviews. Necessary information includes the results of any patient examination, clinical evaluation or second opinion that may be required. For retrospective review determinations, an HMO shall make the determination within thirty (30) days after receiving all necessary information. For a certification, the HMO may give written notification to the Member’s Provider. For a noncertification, the HMO shall give written notification to the Member’s Provider within five (5) business days after making the noncertification.
