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 services are routed to these queues.
What are Retro review queue?
This is the first step when reviewing a Retro request.
What is reviewing the request to determine if Retro criteria are met or check eligibility?
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 for PH IP 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?
Reviewing this helps ensure the authorization reflects the correct dates of service.
What is eligibility review?
What is medical records?
An RFI is needed because the diagnosis and clinical notes are missing, but the member's name, DOB, and ID are present.
What is missing Clinical Information, not Member Demographics?
BH ongoing services prior to PA, what LOU should be on Line 1 and Line 2
What is Retro Line 1, and header LOU Line 2.
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?