Skip to Main Content

Reminder of 12/01/2020 Change in Retroactive Authorization Requests

Date: 01/05/21

This is a notification that effective 12/1/2020 Health Net Health Plan of Oregon Medicare Advantage will be adhering to our policy regarding retroactive review of authorizations. Retroactive authorizations requests may be submitted on the Health Net Prior Authorization Form located at: www.healthnetoregon.com/for-providers/resources/forms-resources.html for Medicare products.

POLICY:
Retro authorization requests are those for which the items or services have already been provided in their entirety and are not ongoing. Requests for items or services still being provided (i.e., Home Health, Oxygen, etc.) are not retro.
 
Retro authorization requests are accepted in the following extenuating circumstances:

  • Catastrophic event that substantially interferes with normal business operations of a provider or damage or destruction of the provider’s business office or records by a natural disaster.
  • Pending or retroactive member eligibility: Provider is required to obtain and verify member coverage, benefits, and eligibility and authorization requirements. The prior authorization request must be submitted within 12 months of the date the member’s caseworker entered the eligibility information.
  • Mechanical or administrative delays or errors by the Contractor or State Office.
  • Provider was unaware that the member was eligible for services at the time that services were rendered and the following conditions are met:
    • The provider’s records document that the member refused or was physically unable to provide their ID card or indicated other coverage
    • Member was unconscious at presentation
    • The provider can substantiate that he/she continually pursued reimbursement from the patient until eligibility was discovered
    • The provider submitted the request for prior authorization within 60 days of the date the eligibility was discovered (excluding retro eligibility)
    • Any situation that the provider cannot determine the exact procedure to be done until after the service has been performed
    • The provider was misinformed that prior authorization was not required. A documented phone log exists or the provider has the name of the plan representative
    • A member has been discharged from an inpatient admission prior to notification to the health plan, and notification was timely
    • Required per state and/or provider contract specifics
    • Services authorized by another payer who subsequently determined member was not eligible at the time of service

CLAIM INFORMATION:
Retro policy applies to both Health Net Medicare and Commercial. If above retro qualifiers are not met, submit claim. To initiate the claims dispute process, choose appropriate link below.

Health Net Commercial:
https://www.healthnetoregon.com/content/dam/centene/healthnet/pdfs/provider/or/HealthNetCommercialProviderDisputeForm.pdf
 
Health Net Medicare:
https://www.healthnetoregon.com/content/dam/centene/healthnet/pdfs/provider/or/HealthNetProviderDisputeForm.pdf