Retrospective Review Process
| Date: | January 10, 2024 |
| To: | Health Plan Practitioners and Facilities |
| Type: | Regulatory |
| Subject: | Retrospective Review Process |
| Business: | Medi-Cal Managed Care |
Effective January 1, 2024, DHCS requires all Managed Care Plans to have a retrospective review process that allows providers to submit requests for care provided without prior authorization.
Health Plan has established the protocol below for retrospective authorization requests in limited circumstances, according to the protocol described below. Since this is a regulatory requirement, this process will be effective the date of this provider alert.
Retrospective Protocol
A network Provider or Practitioner may request retrospective authorization for Covered Services rendered to a member when the request is made 1) within thirty (30) calendar days after the initial date of service, and 2) if one of the following conditions apply:
a. The Member has Other Health Coverage (OHC).
b. The Member has a retrospective eligibility segment; or
c. The Member’s medical condition is such that the Provider or Practitioner is unable to verify the Member’s eligibility for Medi-Cal, and/or Health Plan eligibility at the time of service.
d. The request is for Non-Emergency Medical Transportation (NEMT) provided outside of business hours for members transported from the hospital to home. The request must include a completed Health Plan Physician Certification (PCS) form validating the need for this type of service.
e. Requests for Physical Therapy (PT) can be submitted retrospectively if it is identified upon intake that the member had been treated by a different PT in the past rolling 12 months.
Out-of-network/non-contracted providers are not eligible to request retrospective authorizations.
If while doing an Outpatient procedure, the MD notices that another procedure is necessary but has not been authorized, it is ok to submit a retrospective authorization ASAP, but within 30 calendar days of the service being rendered.
Retrospective eligibility segment: This occurs when a member who is seen by a provider to receive services but does not have Medi-Cal eligibility or it has changed. DHCS will grant eligibility retrospectively and we would honor that as part of this protocol. For example, a member is seen in your office January 5, 2024, and DHCS retrospectively determines the member to be eligible and provides notification in February that the member is eligible from January 1 and forward.
Decision and notification requirements: All requests for retrospective review are required to be determined and a notification to the member and requesting provider within 30 Calendar Days of receipt of all information necessary to make a decision.
Submission Request: When submitting your retrospective authorization request, please include a completed authorization request form with the Retrospective Review box checked and all clinical information demonstrating medical necessity of the request. Please direct questions to your Provider Services Representative who will work with Utilization Management to address your questions.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan of San Joaquin and our services is always available on our website https://www.hpsj.com/