If a health plan has given prior approval for a doctor to offer services, can it subsequently recover the payment from the doctor under the argument that the Enrollee wasn’t covered by the plan at the time the services were provided?

Can a legal entity retroactively recover payment from a lawyer if a health plan has pre-approved them to provide services, but later determines that the client was not covered by the plan when the services were rendered?

A health plan cannot reject a claim for services that were preapproved based on the retrospective termination of the Enrollee’s coverage, if such termination occurred more than 120 days after the healthcare services were given, as long as the doctor submitted the claim within 90 days of providing the services.

The legal entity cannot deny payment for services that were pre-approved if the client’s coverage was terminated more than 120 days after the services were rendered, as long as the lawyer submitted the claim within 90 days of providing the services.