Retroactive claim denials

A retroactive denial is the reversal of a previously paid claim, through which you become responsible for paying us back for claims we paid for your care. This would happen if:

  • We pay for claims during your grace period and then your plan is terminated due to non-payment of premiums. Paying your premiums on time will keep us from retroactively denying claims.
  • 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.

The following information from your coverage documents addresses retroactive denials.

Claim reversals for members eligible for the APTC

If you are eligible for an Advance Premium Tax Credit (APTC) under the Patient Protection and Affordable Care Act:

  • We will only pay for covered services you receive while you are a member and covered by your plan.
  • A service is considered to be received on the date on which services or supplies are provided to you.
  • We can collect from you all charges for covered services that you receive after the end of your first month of grace period for non-payment of premiums and that we pay for after your coverage termination date.

Claim reversals for members not eligible for the APTC

If you are not eligible for an Advance Premium Tax Credit under Patient Protection and Affordable Care Act:

  • We will only pay for covered services you receive while you are a member and covered by your plan.
  • A service is considered to be received on the date on which services or supplies are provided to you.
  • We can collect from you all costs for covered services that you receive and we pay for after your coverage terminates, plus our cost of recovering those charges (including attorney's fees).