Retroactive denials

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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.

Here are common terms and definitions used in retroactive claim denials.

WellFirst Health will not pay for any fees or costs associated with a claim or lawsuit, unless we give prior, express written approval.
WellFirst Health reviews claims both before and after payment. Whenever WellFirst Health finds that any information is fraudulent, misleading, inaccurate, or incomplete, we have the right to reevaluate and retroactively modify our claim payment.

WellFirst Health has this right regardless of whether we have paid some or all of the claim.
Under applicable state law, WellFirst Health may have no right to recover from you if you have not been “made whole.” If requested, WellFirst Health may seek additional information from you so that we may perform a made whole evaluation.
If WellFirst Health pays benefits that exceed those you are entitled to, you must repay the excess as soon as we notify you of the overpayment. WellFirst Health may, at our option, recover some or all of the overpayment by reducing subsequent benefits payable or by applying premium refunds due you.

WellFirst Health has the right to charge reasonable interest on the delinquent amount.
If WellFirst Health pays more than we owe under this policy, WellFirst Health can recover the excess payment from you.

WellFirst Health can also recover from another insurance company or service policy, or from any other person or entity that has received any excess payment from WellFirst Health.
Failure to pay your premium may result in retroactive termination of coverage.

If WellFirst Health has paid claims beyond the resulting retroactive termination date, you will be responsible for these charges, and WellFirst Health 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.
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 WellFirst Health 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.

WellFirst Health 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 WellFirst Health's subrogation rights, to cooperate with us in the enforcement of our subrogation rights, and to take no action, which would prejudice WellFirst Health's subrogation rights and interests without first obtaining our prior consent, so WellFirst Health may protect such rights and interests.

WellFirst Health may be entitled to recover directly from a third party, the third party’s insurer or any other liable insurer. You agree to provide WellFirst Health 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 WellFirst Health's rights to subrogation, unless we have provided prior written consent. Before any settlement is reached, you must notify the third party or parties of the amount of  WellFirst Health's subrogation claim.
If WellFirst Health erroneously pays for or provides medical services that 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 WellFirst Health to the extent of the value of such services.

This information pertains only to our QHP plans.