Retroactive claim denials

A retroactive denial is the reversal of a claim we have already paid. 

This would happen if:

  • You give us wrong or misleading information that affects the coverage  we provide to you.
  • You enroll someone in this plan who is not eligible for coverage. Termination would be effective the day you committed the fraud or were dishonest with us.

We may bill you or the provider

If we pay an amount and it is later shown that a lesser amount should have been paid, we are entitled to a refund of the excess. This applies to payments made to you or to the provider of services, supplies or treatment, or both. We would bill you for any amount we paid you. 

If we take back a payment made to a provider for services you received, the provider may be liable for those services.