Retrospective (Post-Service) Review

It is noted that the majority of determinations made by SWHP are related to benefit coverage interpretations according to the Evidence of Coverage (EOC) and/or Standard Plan Document (SPD) and do not involve issues of medical necessity or appropriateness. Other decisions about medical necessity or appropriateness are made by the SWHP Medical Director(s) with input from the treating clinical Practitioners as appropriate. SWHP benefit determinations are related to payment for care or services based upon input from the Practitioner/Provider and according to the terms of the benefit contract.

Retrospective (Post-Service) review is conducted by the Continuing Care Coordinators (CCCs)/delegated reviewers or the SWHP Claims RN as needed on cases that have been "missed" during the inpatient or concurrent review process due to the types/frequencies of tests/procedures in which the medical records were unavailable or the patient was admitted and discharged from a facility or provider's care before a report could be obtained or records reviewed (i.e., situations in which the case and/or medical records have never been reviewed by SWHP due to circumstances beyond our control. This does not include subsequent review of services for which prospective or concurrent reviews were previously conducted.) When retrospective (Post-Service) review is performed, the review will be based upon written screening criteria (e.g., InterQual® or internally-developed SWHP Screening Criteria) established and annually updated with appropriate involvement from physicians (practicing physicians) and other health care providers.   The CCC/delegated reviewer or Claims RN will review any potential issues with regard to medical necessity or appropriateness with the Plan Medical Director(s). No denials are ever issued without Medical Director review and approval. If any denial is issued, appeal rights are provided to both the Member and the Practitioner or Provider per the requirements of the Texas Department of Insurance (TDI).

Additionally, some retrospective review(s) may be conducted to collect data for health/medical care evaluation studies and are not related to the payment of claims.

For information or clarification on any above noted items, please contact Health Services Division at 254-298-3088 or 1-888-316-7947.

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