Retrospective review allowed only with a permitted ground and complete submission

Prior authorization must be obtained prospectively when required; retrospective requests are reviewed only if they meet a permitted ground in Section A.2 and the submission requirements in Section A.3. Requests that do not meet both are administratively denied without merit review.

• Retrospective requests require documentation of one or more permitted grounds (A.2).
• Submission must include the materials listed in A.3 (e.g., clinical documentation, attestation).

Retrospective PA permitted only when certified grounds and submission requirements met

Prior authorization requiring PA must be obtained prospectively or concurrently; retrospective review is permitted only when a listed permitted ground is certified and the required submission materials are provided, with decisions following ERISA timeframes where applicable.

• If either the permitted-ground certification or submission requirements are missing the request is administratively denied.
• ERISA decision timeframe: 30 days post-service, extendable once by 15 days (when applicable).

Retrospective PA review requirements — submit clinical documentation, attestation, and ground evidence

Retroauthorization will be reviewed only if the provider documents a permitted ground (see C.2/B.3/A.2 as applicable) and submits all required materials through the Plan-designated electronic channel within the plan's submission window (180-day default if silent).

• Required materials include: date of service, CPT/HCPCS and ICD-10 codes, place of service, rendering provider, medical records supporting medical necessity, any conservative-therapy/step-therapy documentation, ground-specific evidence, and a signed provider attestation.
• Submit via Availity, the Plan portal, or another Plan‑accepted electronic channel; phone/fax/email are not accepted unless electronic unavailability is confirmed by the Plan.

Policy covers provider‑initiated requests; Plan may also initiate retrospective review

This policy governs provider-initiated retrospective authorization requests; Curative also reserves the right to conduct Plan‑initiated retrospective review of any claim for medical necessity, coding accuracy, level of care, eligibility, and benefit determination within applicable state and federal timeframes.

• Plan‑initiated retrospective review is independent of the provider‑initiated process described in this policy.
• Plan-initiated reviews follow the statutory timeframes listed (state and federal citations provided).

Follow state PA and electronic PA statutory requirements

Prior authorization and electronic prior authorization must conform to the cited state statutes and regulations where applicable to the member and service location (e.g., Maryland Insurance Article provisions; Indiana Code prior‑authorization and electronic prescription drug PA statutes; D.C. Prior Authorization Reform Act).

• Providers must document compliance with applicable state statutory timelines and disclosure requirements referenced in the policy.
• State citations include Maryland Insurance Article Title 15 and § 15-854 (Prescription Drug PA), Indiana Code Title 27 chapters, and D.C. Code Title 31 Chapter 38F.

Include required step‑therapy/conservative‑therapy documentation with submission

When applicable, include any conservative‑therapy or step‑therapy documentation required by the applicable clinical policy as part of the retrospective submission.

• Clinical policies may require evidence of prior conservative treatments or step‑therapy trials; include that documentation with the request.

Step/conservative‑therapy documentation expected in clinical records

Clinical submission must include any conservative‑therapy or step‑therapy documentation when relevant to the service requested; this documentation is required to evaluate medical necessity for retrospective review.

• Level‑funded and ASO submissions must include clinical records showing prior conservative treatments or step therapies if the clinical policy requires them.

Provide step‑therapy documentation with ASO clinical submission

Include any conservative‑therapy or step‑therapy documentation as part of the clinical submission when relevant to the requested service; lack of such documentation may affect the review.

• ASO submissions must supply medical records supporting necessity and any step‑therapy evidence specified by the clinical policy.

Federal limits on UM: ERISA timeframes, emergency‑service protections, and MHPAEA parity

Federal rules limit UM practices that could affect prior authorization and retrospective review: emergency services cannot be retrospectively denied for failure to obtain PA; ERISA claims‑procedure timeframes and MHPAEA parity requirements apply to ASO/self‑funded business.

• Emergency services are excluded from PA requirements and cannot be retrospectively denied (No Surprises Act and related statutes).
• ERISA timeframes for post‑service decisions: 30 days post‑service, extendable once by 15 days; MHPAEA parity applies to MH/SUD benefits.

Follow state prescription‑drug PA statutes and electronic PA rules

State prescription‑drug PA statutes referenced in the policy may impose additional drug PA or step‑therapy requirements; follow the specific state provisions (e.g., Maryland § 15‑854; Indiana electronic prescription drug PA statutes) when submitting drug PA requests.

• For Maryland, see Maryland Insurance Article § 15‑854 (Prescription Drug PA) and Health‑General § 19‑108.5 (Electronic PA).
• Indiana references include Indiana Code Title 27 Chapter 37.4 (Electronic Prescription Drug PA).

Required clinical and ground‑specific documentation for retrospective requests

The provider must submit the date of service, CPT/HCPCS and ICD‑10 codes, place of service, rendering provider, medical records supporting medical necessity at the time of service, any conservative‑therapy/step‑therapy documentation, and ground‑specific evidence (e.g., prior PA letter, screenshots of portal unavailability).

• Ground‑specific evidence examples: dated screenshots for plan administrative‑error ground; prior authorization letter/number for PA‑issued but not recorded ground.
• One request per service; duplicate submissions for same date of service and CPT/HCPCS code are administratively denied.

Signed provider attestation identifying the permitted ground(s) is required

Include a signed provider attestation identifying which Section A.2 (or B.3/C.2 as applicable) ground(s) apply; false attestations are referred to Payment Integrity.

• The attestation must explicitly identify the permitted ground(s) asserted for retrospective review.
• False attestations will be referred for Payment Integrity review.

Use designated electronic channels and submit within the applicable window

Submit retrospective authorization requests through Availity, the Plan portal, or another Plan‑accepted electronic channel; phone, fax, and email are not accepted unless the Plan confirms electronic‑channel unavailability. Submissions must be within the applicable state or plan document window (180‑day default if silent).

• Designated channels: Availity, Plan portal, or other Plan‑accepted electronic channel.
• Submission windows: follow state‑specific window in A.5/B.5/C.3 or plan document/ASA; 180 days default if silent.

Required submission contents: DOS, codes, place of service, provider, and records

Must submit date of service, CPT/HCPCS and ICD‑10 codes, place of service, rendering provider, and medical records supporting medical necessity at the time of service; include any step‑therapy documentation and ground‑specific evidence.

• Level‑funded submissions follow the plan document or ASA submission window; 180‑day default if silent.
• One request per service; duplicates are administratively denied.

Include tolling evidence when asserting plan error, retro eligibility, or PA issued but not recorded

If asserting plan administrative error, retroactive eligibility, or that a PA was issued but not recorded, include evidence to support tolling and the period of unavailability or notice (e.g., contemporaneous documentation of attempted submission, notice of retroactive enrollment, original claim denial date).

• Plan administrative‑error ground tolls the submission window for the documented period of channel unavailability.
• Retroactive eligibility grounds start the clock when provider received notice of Curative's responsibility; PA‑issued but not recorded starts at the original claim denial date.

Provide full clinical documentation and ground evidence with the request

Submit date of service, CPT/HCPCS and ICD‑10 codes, place of service, rendering provider, medical records supporting medical necessity at the time of service, any conservative‑therapy or step‑therapy documentation, and ground‑specific evidence as part of the clinical submission.

• Ground‑specific evidence and attestation are required for ASO retrospective requests.
• Lack of required documentation will lead to administrative denial.

Signed permitted‑ground attestation required for ASO submissions

Include a signed provider attestation identifying which permitted ground(s) from Section C.2 apply; false attestations are referred to Payment Integrity.

• Attestation requirement applies to ASO/self‑funded submissions as described in C.3.
• The attestation must be signed by the provider.

Submit electronically via Availity or Plan portal and follow the plan‑document/window rules

Use designated electronic channels (Availity, the Plan portal, or another Plan‑accepted electronic channel) and comply with the plan document or administrative services agreement submission window; 180 days from date of service is the default if the plan document/ASA is silent.

• Phone, fax, and email are not accepted unless the Plan confirms electronic unavailability.
• Ensure submissions meet the plan document/ASA timelines or the 180‑day default if silent.

Denial notices must explain reasons, plan provisions relied on, and appeal/review rights

Adverse benefit determination notices (where applicable) must state the specific reasons for denial, reference the specific plan provisions relied upon, describe additional material needed to perfect the claim, and describe internal appeal and external review rights and time limits.

• If ERISA adverse benefit determination, include the specific internal rule, guideline, protocol, or medical‑necessity criterion relied upon or state that a copy is available free of charge on request.

Document compliance with cited state statutes for provider awareness

Policy references specific state statutes and code sections (Maryland, Indiana, D.C.) that govern claims, utilization review, prior authorization, electronic PA, grievances, and prompt payment; providers should document compliance with applicable state statutory timelines and disclosure requirements.

• Maryland citations include Maryland Insurance Article Title 15 and § 15‑854 (Prescription Drug PA) and Health‑General § 19‑108.5 (Electronic PA).
• Indiana and D.C. statutory references are listed and may impose unique submission or processing rules.

Administrative denial if permitted ground or submission requirements are missing

Requests that do not meet a permitted ground (Section A.2/B.3/C.2) and the submission requirements (Section A.3/B.4/C.3) are administratively denied without merit review.

• Administrative denials are issued when either the permitted‑ground certification or required submission materials are missing.
• Denials for missing requirements do not undergo medical‑necessity review.

Duplicate submissions for same DOS and code will be denied

Duplicate submissions for the same date of service and CPT/HCPCS code are administratively denied.

• One request per service is required; disagreement about duplicates is addressed through appeal.
• Duplicate requests may be returned administratively without clinical review.

Administrative denial for insufficient grounds or incomplete submission

Retrospective authorization requests that do not meet both a permitted ground and the submission requirements are administratively denied without merit review; ensure both are met before submitting.

• Level‑funded and other plan types follow the same rule: both grounds and submission requirements must be satisfied.
• If either condition is not met the request is administratively denied.

Multiple requests for the same service will be administratively denied

Duplicate requests (more than one request per service) are administratively denied.

• Level‑funded submissions also require one request per service; duplicates are administratively denied.
• Ensure only a single retrospective request is submitted per service to avoid administrative denial.

Duplicate submission denial (one‑request‑per‑service rule)

Duplicate submissions for the same date of service and CPT/HCPCS code are administratively denied (this policy reiterates the one‑request‑per‑service requirement).

• Duplicates are administratively denied and disagreement is handled through appeal processes.

ASO: duplicate request denial for multiple submissions per service

Duplicate requests (more than one request per service) are administratively denied; submit a single complete request per service.

• ASO submissions specify one request per service; duplicates will be administratively denied.
• If a duplicate is submitted in error, resolve via the appeals process.

Plan‑initiated retrospective review can trigger denials for clinical and coding issues

Plan‑initiated retrospective review may deny claims for medical necessity, coding accuracy, level of care, eligibility, and benefit determination within applicable state and federal timeframes.

• Plan‑initiated reviews are independent of provider‑initiated retrospective authorization requests.
• Such plan‑initiated denials may result from post‑payment audits or utilization review within statutory timeframes.

Maryland statutory risks: follow Maryland Insurance Article requirements

Maryland providers should be aware of Maryland Insurance Article requirements (claims and utilization review, prompt payment, provider claim‑submission floors, adverse decision/grievance rules, prescription drug PA, and electronic PA) that could affect claim processing and denials.

• Examples include Maryland Insurance Article § 15‑1005 (prompt payment and 180‑day provider claim‑submission floor) and § 15‑854 (Prescription Drug PA).
• Document compliance with Maryland‑specific statutory timelines and disclosure requirements referenced in the policy.

Indiana statutory risks: follow Indiana PA and e‑prescription PA rules

Indiana statutes on prior authorization and electronic prescription drug PA may create state‑specific denial or processing risks if statutory requirements are not followed; note Indiana has no statutory provider claim‑submission floor under the cited provision.

• Indiana Code Title 27, Article 1, Chapter 37.5 (Prior Authorization) and Chapter 37.4 (Electronic Prescription Drug PA) are cited.
• Indiana Code § 27‑8‑5.7 addresses prompt pay and notes there is no statutory provider claim‑submission floor.

D.C. statutory risks: comply with Prior Authorization Reform Act and submission floor rules

D.C. statutory provisions (Prior Authorization Reform Act and related code sections) and provider claim‑submission floor rules may affect retrospective authorization decisions and potential denials; comply with D.C. timelines and requirements.

• Relevant citations include D.C. Code Title 31, Chapter 38F and § 31‑3132(g) (180‑day provider claim‑submission floor).
• D.C. Prior Authorization Reform Act provisions may alter processing and denial risks.