A retroactive denial is the reversal of a claim we've already paid. If we retroactively deny a claim we have already paid for you, you are responsible for payment. Some reasons why you might have a retroactive denial include:
You can avoid retroactive denials by paying your premiums on time and in full — and making sure you talk to your provider about whether the service performed is a covered benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network provider.
If you have questions, contact us at 866-514-4194 (TTY: 711) or the number on the back of your member ID card. You can also submit a form to our Customer Care Center.
Here are common terms and definitions used in retroactive claim denials.
This information pertains only to our QHP plans