UM Operations
Retrospective Review
Draft — pending verification
This reference entry has not yet been verified against its authoritative source (Original definitions; regulatory facts to be verified against CMS-0057-F (89 FR 8758) and X12/HL7 documentation). Do not rely on it for production configuration until this notice is removed.
In more depth
Retrospective denials are the most contentious UM outcome because care already happened and someone must absorb the cost. Regulation and contracts increasingly constrain retrospective denial of previously authorized care; "authorization is not a guarantee of payment" language is under sustained policy pressure.