Retroactive denials

A retroactive denial occurs when it is discovered that a claim that was processed and paid, but which should not have been paid by Health Advantage, is reprocessed and denied. In such cases, the enrollee may become responsible for paying the amount billed. A claim may be retroactively denied:

• if the premium payments are not made,
• if the health plan was not notified of other insurance coverage, or
• if the provider submits a corrected bill.

To prevent retroactive denials, make sure that premium payments are made in a timely manner and that you have told Health Advantage about any other health plan coverage. Despite our best efforts, we may make a claim payment which is not for a benefit provided under your plan. In the event of an erroneous or mistaken payment, a refund will be requested. If you have questions regarding a retroactive denial please contact customer service at 800-800-4298 or email Exchange Customer Service.