Retroactive denials

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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:

  • Having a claim that was paid during the second or third month of a grace period 
  • Having a claim paid for a service for which you were not eligible. 

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.

Here are common terms and definitions used in retroactive claim denials.

This information pertains only to our QHP plans.