NY Manual
SHP Manual

New York Provider Manual
12.6 Concurrent Review | 13.1 Overview

12.7 Retrospective Review

Retrospective reviews are performed after healthcare services have been provided. Healthfirst conducts retrospective reviews to evaluate the medical necessity for services that were not preauthorized or reviewed concurrently. Healthfirst will make retrospective determinations within 30 (thirty) days of Healthfirst receiving the necessary information. Notices will be sent to members on the date of a full or partial payment denial in the form of a Explanation of Benefits (EOB)

We may reverse a preauthorized treatment, service, or procedure on retrospective review only when:

  • The relevant medical information presented to us upon retrospective review is materially different from the information presented during the preauthorization review;

  • The relevant medical information presented to us upon retrospective review existed at the time of thepreauthorization but was withheld or not made available to us;

  • We were not aware of the existence of such information at the time of the preauthorization review;

  • The treatment, service, or procedure being requested would not have been authorized had we been awareof such information;

  • The determination is made using the same specific standards, criteria, or procedures as used during thepreauthorization review.