Retroactive denials
A retroactive denial is the reversal of a claim we've already paid. If we retroactively deny a claim we have already paid for you, you are responsible for payment. Some reasons why you might have a retroactive denial include:
- having a claim that was paid during the second or third month of a grace period
- having a claim paid for a service for which you were not eligible.
You can avoid retroactive denials by paying your premiums on time and in full — and making sure you talk to your provider about whether the service performed is a covered benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network provider.
Common terms and definitions used in retroactive claim denials.
If you have questions, visit our Contact Us page.
Note: Claims may be denied retroactively, even after the enrollee has obtained services from the provider
Recovery of excess payments
If Prevea360 Health Plan pays more than we owe under this policy, Prevea360 Health Plan can recover the excess payment from you. We can also recover from another insurance company or service policy, or from any other person or entity that has received any excess payment from Prevea360 Health Plan.
Fraudulent, misleading, inaccurate or incomplete claims information
Prevea360 Health Plan reviews claims both before and after payment. Whenever Prevea360 Health Plan finds that any information is fraudulent, misleading, inaccurate, or incomplete, We have the right to reevaluate and retroactively modify our claim payment. Prevea360 Health Plan has this right regardless of whether we have paid some or all of the claim.
Overpayments
If Prevea360 Health Plan pays benefits that exceed those you are entitled to, you must repay the excess as soon as we notify you of the overpayment. Prevea360 Health Plan may, at our option, recover some or all of the overpayment by reducing subsequent benefits payable or by applying premium refunds due you. We have the right to charge reasonable interest on the delinquent amount.
Retroactive terminations
Failure to pay your premium may result in retroactive termination of coverage. If Prevea360 Health Plan has paid claims beyond the resulting retroactive termination date, you will be responsible for these charges and we will recover the excess payment from you. You can avoid a retroactive termination by paying your premiums in a timely manner and keeping us informed of any changes in your dependents' eligibility status.
Subrogation and reimbursement
If you are entitled to special damages for an illness or injury caused by a third party or for which any party is liable, you agree that Prevea360 Health Plan have a claim for subrogation as to those damages. Our subrogation claim is for the reasonable value of the medical care and services you receive related to that illness or injury. Prevea360 Health Plan has the right to recover payments you are entitled to receive from: a responsible third party, the insurance company of the third party, a company that provides medical payment coverage, Workers Compensation coverage, or uninsured or underinsured motorist protection for you.
You agree to honor Prevea360 Health Plan's subrogation rights, to cooperate with Prevea360 Health Plan in the enforcement of Prevea360 Health Plan subrogation rights, and to take no action, which would prejudice Prevea360 Health Plan's subrogation rights and interests without first obtaining Prevea360 Health Plan prior consent, so Prevea360 Health Plan may protect such rights and interests.
Prevea360 Health Plan may be entitled to recover directly from a third party, the third party’s insurer or any other liable insurer. You agree to provide Prevea360 Health Plan with written notice of any claim or lawsuit that you initiate against a third party, if that claim or lawsuit includes any special damages for an illness or injury. You also agree that any settlement or compromise of a claim or lawsuit will not terminate Prevea360Health Plan rights to subrogation, unless Prevea360 Health Plan has provided prior written consent. Before any settlement is reached, you must notify the third party or parties of the amount of Prevea360Health Plan subrogation claim.
Made whole
Under applicable state law, Prevea360 Health Plan may have no right to recover from you if you have not been “made whole.” If requested, Prevea360 Health Plan may seek additional information from you so that Prevea360Health Plan may perform a made whole evaluation.
Common fund
Prevea360 Health Plan will not pay for any fees or costs associated with a claim or lawsuit, unless Prevea360 Health Plan gives prior, express written approval.
Workers' compensation
If Prevea360 Health Plan erroneously pay for or provide medical services which are the result of a work-related illness or injury for which the employee may be eligible for workers’ compensation benefits, you agree to reimburse Prevea360 Health Plan to the extent of the value of such services.
This information pertains only to our QHP plans