NY Manual
SHP Manual

New York Provider Manual
12.7 Concurrent Review | 13.1 Overview

12.8 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 thirty (30) days of Healthfirst receiving the necessary information.  

We may only reverse a preauthorized treatment, service, or procedure on retrospective review 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 the preauthorization 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; and
·     had we been aware of such information, the treatment, service, or procedure being requested would not have been authorized;
·     the determination is made using the same specific standards, criteria, or procedures as used during the preauthorization review.