Retro Basics
This resource should be reviewed before determining whether a request is Retro or Standard.
What is the Intake OneNote or Retro Job Aid?
This should be verified before building the authorization.
What is member eligibility?
This should be sent when required information is missing.
What is an RFI, or Request for Information?
This determines the correct queue assignment.
What is the service type and urgency?
These requests generally involve services that have already been rendered.
What are Retro requests?
Eligibility findings may require changes to these.
What are authorization dates?
Missing this information often triggers an RFI.
What is clinical documentation or clinical information?
Completed physical health services are routed to one of these queues.
What are Retro review queues?
This is the first step when reviewing a Retro request.
What is reviewing the request to determine if Retro criteria are met?
When eligibility changes authorization dates, this action is required.
What is documenting the change in authorization notes?
After an RFI is sent, this action should be documented.
What is documenting the RFI activity in TruCare and notes?
Ongoing services may require routing to this type of review.
What is Concurrent review?
A common processing error that can create SLA risk.
What is delayed processing, failure to identify a Retro request, or delayed RFI action?
This review helps ensure the authorization reflects the correct dates of service.
What is eligibility review?
These requests should not be forwarded without required information.
What are requests missing required clinical documentation?
Behavioral Health retro requests may be routed to this queue.
What is the Behavioral Health or Appeals queue, depending on market guidance?
Services delivered without prior authorization may qualify under this type of review.
What is retrospective review?
Failure to complete this review may result in incorrect authorization dates.
What is eligibility verification?
This department reviews the clinical information after Intake processing.
What is the Clinical team?
Incorrect routing of requests can impact this metric.
What is SLA compliance?