Retroactive Eligibility
Process retroactive enrollment changes, assess claim impact, and manage approval workflow
23
Pending Retro Requests
$184K
Estimated Impact MTD
90
Max Retro Days (Policy)
5
Overdue Approvals
New Retro Eligibility Request
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Impact Preview — Review Before Submitting
14
Claims Affected
$8,420
Financial Impact
Affected Services: 3 office visits, 2 lab panels, 1 specialist consult, 8 Rx fills
Claims Period: Jan 15 – Mar 1, 2025
Action Required: 14 claims will be reprocessed automatically upon approval
Claims Period: Jan 15 – Mar 1, 2025
Action Required: 14 claims will be reprocessed automatically upon approval
Approval Workflow
1
Enrollment Specialist — Submits request with supporting docs
Current
2
Enrollment Manager — Reviews impact and approves (≤ $5K)
Pending
3
Finance Director — Required for impact > $5K
If Needed
Retroactive Limit Rules
• Standard limit: 90 days prior to request date
• Medicaid retro: Up to 3 months (federal limit)
• Court orders: No time limit — requires legal documentation
• Newborns: Retro to date of birth always allowed
• All retros require supervisor approval and audit log
• Medicaid retro: Up to 3 months (federal limit)
• Court orders: No time limit — requires legal documentation
• Newborns: Retro to date of birth always allowed
• All retros require supervisor approval and audit log
Pending Retro Requests
| Req ID | Member | Original Date | Retro Date | Reason | Claims | Impact $ | Submitted By | Status | Actions |
|---|---|---|---|---|---|---|---|---|---|
| RET-2025-0041 | Maria Santos | 03/01/2025 | 01/01/2025 | Late 834 | 8 | $3,220 | J. Torres | Mgr Review | |
| RET-2025-0040 | Kevin Dunn | 02/01/2025 | 11/01/2024 | Medicaid | 14 | $8,420 | A. Lin | Finance Review | |
| RET-2025-0038 | Lisa Chen | 03/01/2025 | 02/01/2025 | System Error | 2 | $440 | System | Approved | |
| RET-2025-0035 | Newborn — Huang | 03/15/2025 | 03/02/2025 | Newborn | 5 | $1,840 | A. Lin | Approved |
Audit Trail
RET-2025-0035 Approved — A. Lin · Today 10:22 AM
Newborn retro enrollment for Baby Huang — DOB Mar 2, 2025. 5 claims queued for reprocessing.
RET-2025-0038 Approved (Auto) — System · Today 9:05 AM
System error correction — auto-approved per policy (impact < $500). 2 claims reprocessed.
RET-2025-0040 Escalated to Finance — J. Torres · Yesterday 3:14 PM
Impact $8,420 exceeds $5K threshold. Routed to Finance Director for approval.
RET-2025-0041 Submitted — J. Torres · Yesterday 2:48 PM
Late 834 from ABC Employer Group received Mar 18. Retro requested to Jan 1.