Medical Management

Medical Management Retrospective Review

Post-service decisions are determinations of medical necessity and/or appropriate level of care when the care has already been received, for example, retrospective review.

Notification of post-service decision denial determinations are given electronically or in writing to the practitioner and member within 30 calendar days of the request.

All potential post-service denial decisions based on medical necessity or appropriate level of care are reviewed by the Medical Director and a determination made by him, or his designee.