Medical necessity criteria help determine whether a service, treatment, or supply is appropriate and covered under your health plan.
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Coverage decisions
Understand how coverage determinations are made for healthcare services, treatments, and prescription drugs.
Medical Necessity Guidelines
Prior authorization requirements
Some services and medications require approval before care is received. Learn what prior authorization is and how the review process works.
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Retroactive claim denials
A retroactive denial happens when a claim that was previously paid is later denied. If this occurs, you may be responsible for paying for the services received.
This can happen for reasons such as:
- A claim was paid during the second or third month of a grace period, but premiums were not paid in full.
- A claim was paid for services received when you were not eligible for coverage.
How to Help Avoid a Retroactive Denial
You can reduce the risk of a retroactive denial by:
- Paying your premiums in full and on time.
- Checking that the services you receive are covered by your health plan.
- Using providers in your plan's network whenever possible.
- Asking your provider if a service requires authorization or has coverage limitations before receiving care.
Grace periods and pending claims
A grace period may apply when premium payments are overdue. Learn how claims may be handled during this period.
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