Retroactive denials

Business people having a discussion around a table in front of a large window.

A retroactive denial is a reversal of a previously paid claim – which then means the enrollee then becomes responsible for payment.

Here are common terms and definitions used in retroactive claim denials. We have also outlined the outcomes and processes used at WellFirst Health — Provided by SSM Health Plan — if you were to submit a claim.

WellFirst Health will not pay for any fees or costs associated with a claim or lawsuit, unless we give prior, express written approval.
 
We review claims both before and after payment. Whenever we find that any information is fraudulent, misleading, inaccurate, or incomplete, we have the right to reevaluate and retroactively modify our claim payment.

We have this right regardless of whether we have paid some or all of the claim.
Under applicable state law, we may have no right to recover from you if you have not been “made whole.” If requested, we may seek additional information from you so that we may perform a made whole evaluation.
 
If we pay benefits that exceed those you are entitled to, you must repay the excess as soon as we notify you of the overpayment. We may, at our option, recover some or all of the overpayment by reducing subsequent benefits payable or by applying premium refunds due you.

We have the right to charge reasonable interest on the delinquent amount.
 
If we pay more than we owe under this policy, we can recover the excess payment from you.

We can also recover from another health plan company or service policy, or from any other person or entity that has received any excess payment from us.
Failure to pay your premium may result in retroactive termination of coverage.

If we have paid claims beyond the resulting retroactive termination date, you will be responsible for these charges, and we will recover the excess payment from you.

You can avoid a retroactive termination by paying your premiums in a timely manner and keeping us informed of any changes in your dependents' eligibility status.
 
If you are entitled to special damages for an illness or injury caused by a third party or for which any party is liable, you agree that we have a claim for subrogation as to those damages. Our subrogation claim is for the reasonable value of the medical care and services you receive related to that illness or injury.

We have the right to recover payments you are entitled to receive from: a responsible third party, the insurance company of the third party, a company that provides medical payment coverage, Workers Compensation coverage, or uninsured or underinsured motorist protection for you.

You agree to honor our subrogation rights, to cooperate with us in the enforcement of our subrogation rights, and to take no action, which would prejudice our subrogation rights and interests without first obtaining our prior consent, so we may protect such rights and interests.

We may be entitled to recover directly from a third party, the third party’s insurer or any other liable insurer. You agree to provide us with written notice of any claim or lawsuit that you initiate against a third party, if that claim or lawsuit includes any special damages for an illness or injury.

You also agree that any settlement or compromise of a claim or lawsuit will not terminate our rights to subrogation, unless we have provided prior written consent. Before any settlement is reached, you must notify the third party or parties of the amount of our subrogation claim.
If we erroneously pay for or provides medical services that are the result of a work-related illness or injury for which the employee may be eligible for workers’ compensation benefits, you agree to reimburse us to the extent of the value of such services.
 

This information pertains only to our QHP plans