CurrentAmeriHealth Caritas LouisianaPolicy UM.200

Post Service Review

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Governs retrospective review of medical services provided to AmeriHealth Caritas Louisiana members when required authorization was not obtained before service delivery, including Louisiana-specific retroactive-enrollment requirements, review timeframes, claims, eligibility verification, and appeals.

Policy Summary

PayerAmeriHealth Caritas Louisiana

PolicyPost Service Review

Policy CodePolicy UM.200

Change TypeAnnual reviewno material clinical or coverage changes

Effective DateJan 1, 2026

Last ReviewJan 1, 2026

Next Review DateJan 1, 2027

Key ActionSubmit retrospective review requests and required information no later than 180 days from the date of service or inpatient discharge.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review removed plans that were no longer part of the organization.

The policy was transitioned from plan policy 153.200 to corporate base policy UM.200 with a Louisiana-specific addendum and retrospective review timeframe.

180 daysGeneral submission deadline

30 daysLouisiana determination timeframe

365/180 daysRetroactive-enrollment claim deadline

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CurrentAmeriHealth Caritas LouisianaPolicy UM.200

Post Service Review

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Policy Summary

PayerAmeriHealth Caritas Louisiana

PolicyPost Service Review

Policy CodePolicy UM.200

Change TypeAnnual reviewno material clinical or coverage changes

Effective DateJan 1, 2026

Last ReviewJan 1, 2026

Next Review DateJan 1, 2027

Key ActionSubmit retrospective review requests and required information no later than 180 days from the date of service or inpatient discharge.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review removed plans that were no longer part of the organization.

The policy was transitioned from plan policy 153.200 to corporate base policy UM.200 with a Louisiana-specific addendum and retrospective review timeframe.

180 daysGeneral submission deadline

30 daysLouisiana determination timeframe

365/180 daysRetroactive-enrollment claim deadline

12 monthsRetroactive-enrollment lookback

5Eligible review circumstances

Retrospective Review Coverage Criteria

When Retrospective Review May Be Performed

Retrospective or post-service review may be performed when authorization was not obtained before service delivery and any of the following circumstances applies:

ONE of the following

The member obtained retroactive eligibility.
Pertinent coverage information was unavailable or incorrect upon admission or at the time of service.
An out-of-state facility treated the member emergently or urgently.
The provider can show that attempts were made to submit the request before service, but the plan did not receive the request.
Specific provider contract terms permit retrospective review.

Medical Necessity Approval

Requested services may be approved when ALL of the following are met:

ALL of the following

Clinical information is submitted for the requested service.
The service meets AmeriHealth Caritas Louisiana's accepted Utilization Management Criteria.
The determination is documented and communicated under the applicable response-time policy.

Denial, Alteration, or Reduced Scope

Coverage may be denied, altered, or reduced when ANY of the following applies. Required decision-maker and notice rules also apply:

ONE of the following

The service is not medically necessary under applicable Utilization Management Criteria.
The provider failed to follow applicable contractual requirements, supporting an administrative denial where applicable.
The requested service is denied, altered, or approved at a lower or different level of care or scope by the Medical Director, Behavioral Health Medical Director, or physician designee.
A UM Reviewer may not make a denial, downgrade, or alteration. The requesting Practitioner or Provider and/or Member must be notified of the determination and applicable appeal rights.

Louisiana Retroactive-Enrollment Coverage Rules

Louisiana retroactive-enrollment claims are subject to ALL of the following rules:

ALL of the following

The enrollee was retro-enrolled and the service was provided during the retrospective enrollment period.
The claim is not denied for timely filing, prior authorization, or precertification edits.
The plan may still conduct post-service medical necessity review and may deny the claim if the service was not medically necessary.
The provider has the right to appeal a denial.

Coding and Review Timeframes

Diagnosis and procedure informationmixed

No codes listed

General Retrospective Review Deadline

Submission deadlineNo later than 180 calendar days

Starting dateThe deadline is calculated from the date of service

Inpatient servicesFor inpatient services, the deadline is calculated from the member's date of discharge

Louisiana Retrospective Determination Timeframe

Determination timeframeWithin 30 calendar days of obtaining the results of any appropriate required medical information

Required informationThe timeframe begins when the results of required medical information are obtained

Provider Responsibilities

Note

Submit Retrospective Review Requests

Submit retrospective review requests to the AmeriHealth Utilization Management department through an accepted channel. Requests may be sent electronically, by telephone, fax, or in writing.

Documentation Required

Provide Diagnosis and Procedure Information

Submit the diagnosis and procedure information for the service being considered for authorization. Applicable diagnosis and procedure codes are preferred but are not required.

Prior Authorization

Meet Retrospective Review Timeframes

Meet the applicable retrospective review submission and determination deadlines.

Key Definition

Member

MemberAn enrollee, participant, recipient, or beneficiary

EnrolleeA person included within the definition of member

ParticipantA person included within the definition of member

Recipient or beneficiaryA person included within the definition of member

Policy Summary

PayerAmeriHealth Caritas Louisiana

PolicyPost Service Review

Policy CodePolicy UM.200

Change TypeAnnual reviewno material clinical or coverage changes

Effective DateJan 1, 2026

Last ReviewJan 1, 2026

Next Review DateJan 1, 2027

Key ActionSubmit retrospective review requests and required information no later than 180 days from the date of service or inpatient discharge.

SourceLink

On This Page

Outer deadlineIn no instance later than 180 calendar days from receipt of the service authorization request

Louisiana Retroactive-Enrollment Claim Filing

Date-of-service deadline365 calendar days from the date of service

MCO linkage deadline180 calendar days from the enrollee's MCO linkage add date in the enrollee's 834 file

Applicable deadlineThe later of the date-of-service deadline or the MCO linkage add-date deadline

Louisiana Retroactive-Enrollment Lookback

Maximum lookbackUp to 12 months before the enrollee's linkage add date

Eligibility periodThe retrospective enrollment period is the time between when the enrollee becomes eligible and when the enrollee is linked to ACLA

Linkage referenceThe lookback is measured from the enrollee's linkage add date

Request and supporting information must generally be received no later than 180 calendar days from the date of service or the Member’s discharge date from an inpatient facility.
For Louisiana, retrospective review determinations must be made within 30 calendar days after obtaining the results of any appropriate medical information required, and no later than 180 calendar days from receipt of the service-authorization request.

Note

Identify an Eligible Post-Service Review Circumstance

Retrospective or post-service review may be appropriate when one of the following circumstances applies.

The Member obtains retroactive eligibility.
Pertinent coverage information was unavailable or incorrect at admission or when services were provided, such as when the Member presented as self-pay or had an altered level of consciousness.
An out-of-state facility treated the Member on an emergency or urgent basis.
The Provider can show that it attempted to submit the request before the service, but the Plan did not receive it.
Specific Provider contract terms support retrospective review.

Note

Accept Member-Initiated Requests

Accept oral or written Member requests for retrospective review of initial services or continuation of previously requested services when a Provider refuses the service or does not request it within the appropriate timeframe.

Documentation Required

Submit Supporting Clinical Information

Submit the clinical records and supporting information needed for the retrospective review determination.

Medical history, including mental health and substance-abuse history
History of present illness, presenting symptoms, current clinical status, and prior treatment outcomes
Plan of care, emergency-room treatment, current treatment, and discharge plan
Information about the condition and instructions provided at a prior discharge

Unsupported block type: prior_auth

Denial Risk

Medical Director Authority for Adverse or Reduced Determinations

The UM Reviewer may not deny, alter, or approve a lower or different level of care or scope of services than requested. Any denial, downgrade, alteration, or different level-of-care determination must be made by the Medical Director, BH Medical Director, or physician designee after review of the individual Member’s needs and submitted clinical information.

The Medical Director, BH Medical Director, or physician designee may consult a specialty Practitioner/Provider when needed.
The determination must be documented in the medical management information system.

Denial Risk

Notify Parties and Provide Appeal Rights

Notify the requesting Practitioner/Provider and, when applicable, the Member of any determination to deny, alter, or approve a lower or different level of care or scope of services than requested. Provide the reason for the decision and applicable appeal rights in accordance with the adverse-benefit-determination requirements.

Unsupported block type: documentation

Billing Rule

Apply Louisiana Retro-Enrollment Claim Protections

Apply Louisiana protections to claims for services provided during a verified retrospective enrollment period.

Providers have 365 calendar days from the date of service or 180 calendar days from the Enrollee’s MCO linkage add date in the 834 file, whichever is later, to submit applicable claims.
Do not deny these claims for timely-filing, prior-authorization, or precertification edits.
Do not require the Provider to submit the Enrollee’s eligibility-determination award letter.
Post-service medical-necessity review may still be performed; a claim may be denied if the service is determined not medically necessary.
The Provider has the right to appeal a denial.

Documentation Required

Document and Communicate the Determination

Document retrospective review determinations in the appropriate medical information system to support claim payment and communicate the determination to the requesting Practitioner/Provider within the applicable response timeframe.

The documentation system generates and stores an authorization number and authorization effective dates for servicing and requesting Providers, regardless of contracted status.
The UM Reviewer is responsible for communicating the determination to the requesting Practitioner/Provider.
Any decision to deny or limit coverage must be communicated in writing to the facility, attending physician, and/or Member, as applicable.
Handle protected health information in accordance with applicable privacy and security policies and law.

Billing Rule

Apply Medical-Record Cost Reimbursement Terms

AmeriHealth reimburses Providers for the cost of supplying medical information, including copying, only when the Provider’s participation agreement expressly provides for that payment.