What Is a Retroactive Denial of a Claim
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Explains what a retroactive denial is and outlines steps members and providers can take to prevent previously paid claims from being reversed and billed back to them. Applies to Alliant Health members (SoloCare referenced) and providers interacting with claims.
No material clinical or coverage changes in this revision.
Key Definitions
Preventable Causes and How to Avoid Retroactive Denials
Preventable causes of retroactive denial
Circumstances that can lead to retroactive denial and recommended member/provider actions to prevent them.
ONE of the following may lead to retroactive denial unless addressed
- Untimely or unpaid premiums: Pay your SoloCare (Individual/Family) plan premiums on time and in full every month to avoid retroactive denials.
- Lack of prior authorization for out-of-network services: If you use an Out-of-Network Provider, confirm any prior authorizations for medical services before the appointment/procedure; your provider will be assigned a prior authorization reference number.
- Other insurance coverage not disclosed: Inform Alliant Health of any other insurance coverage. If another payer is primary to Alliant, claims may be retroactively denied and you may be responsible.
- Service determined non-covered: Contact Client Services at (866) 403-2785 prior to any service to confirm it is a covered benefit; services determined non-covered per your Certificate of Coverage exclusions may be retroactively denied and you may be responsible.
Provider Steps to Prevent Retroactive Denials
Confirm prior authorization before appointments/procedures
Confirm any prior authorizations for medical services before appointments or procedures; providers will be assigned a prior authorization reference number for the requested service.
Utilization Management contact for authorization verification
Verify prior authorization status by contacting Utilization Management at (800) 865-5922 or by calling the phone number listed on the back of the member's ID card.
- UM phone: (800) 865-5922
- Alternatively call the number on the member's ID card
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