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:
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 other common terms and definitions used in retroactive claim denials. If you have more questions, contact us.
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 Dean 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. Dean 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 Dean Health Plan's subrogation rights, to cooperate with Dean Health Plan in the enforcement of Dean Health Plan subrogation rights, and to take no action, which would prejudice Dean Health Plan's subrogation rights and interests without first obtaining Dean Health Plan prior consent, so Dean Health Plan may protect such rights and interests.
Dean 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 Dean 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 Dean Health Plan rights to subrogation, unless Dean Health Plan has provided prior written consent. Before any settlement is reached, you must notify the third party or parties of the amount of Dean Health Plan subrogation claim.
This information pertains only to our QHP plans